Provider Demographics
NPI:1700404415
Name:RUTHERFORD, CONNOR BLAINE
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:BLAINE
Last Name:RUTHERFORD
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 1:3625 NW 56TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4509
Mailing Address - Country:US
Mailing Address - Phone:405-951-2855
Mailing Address - Fax:
Practice Address - Street 1:3625 NW 56TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4509
Practice Address - Country:US
Practice Address - Phone:405-951-2855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program