Provider Demographics
NPI:1619965548
Name:CONNELLY, PATRICK WELLINGTON (MD)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:WELLINGTON
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:PATRICK
Other - Middle Name:WELLINGTON
Other - Last Name:CONNELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5300 S SUTTER DR
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-8050
Mailing Address - Country:US
Mailing Address - Phone:928-537-9844
Mailing Address - Fax:928-537-4437
Practice Address - Street 1:5300 S SUTTER DR
Practice Address - Street 2:SUITE 11
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-8050
Practice Address - Country:US
Practice Address - Phone:928-537-9844
Practice Address - Fax:928-537-4437
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34632207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1255429353OtherGROUP NPI