Provider Demographics
NPI:1710092861
Name:O'CONNOR, BRIAN JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:PA-C
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 531797
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-1797
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2134
Practice Address - Country:US
Practice Address - Phone:704-867-2141
Practice Address - Fax:704-867-2308
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102119363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0360PAMedicaid
NC8101097Medicaid
NCNC4031EMedicare PIN
NCNC4031LMedicare PIN
NC8101097Medicaid
NCNC4031HMedicare PIN
NCNC4031JMedicare PIN
NCNC4031KMedicare PIN
NCNC4031BMedicare PIN
NC2799894BMedicare UPIN
SC0360PAMedicaid
NCNC4031GMedicare PIN
NCNC4031NMedicare PIN
NCNC4031DMedicare PIN
NCNC4031AMedicare PIN
NC2750183DMedicare PIN
NCNC4031MMedicare PIN
NC2799894AMedicare PIN