Provider Demographics
NPI:1689459364
Name:VINO, CONNOR
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:VINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412239
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2239
Mailing Address - Country:US
Mailing Address - Phone:833-292-2663
Mailing Address - Fax:973-898-1636
Practice Address - Street 1:100 MADISON AVE FL 1
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:833-292-2663
Practice Address - Fax:973-898-1636
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00801700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty