Provider Demographics
NPI:1588637458
Name:MCCONNELL, RICHARD ALLEN (MPT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5158
Mailing Address - Country:US
Mailing Address - Phone:575-622-4922
Mailing Address - Fax:
Practice Address - Street 1:113 E COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5158
Practice Address - Country:US
Practice Address - Phone:575-622-6500
Practice Address - Fax:575-622-9777
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98238370Medicaid
NMNMA100044Medicare UPIN