Provider Demographics
NPI:1669845657
Name:CONNER, BRANDON LEE
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:CONNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:LEE
Other - Last Name:CONNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 173891
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3891
Mailing Address - Country:US
Mailing Address - Phone:303-306-7101
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
COPA0004474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO464639YMGXMedicare PIN