Provider Demographics
NPI:1710614201
Name:BALDERSTON, CONNOR CHARLES
Entity Type:Individual
Prefix:MR
First Name:CONNOR
Middle Name:CHARLES
Last Name:BALDERSTON
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 1:151 W 7TH AVE
Mailing Address - Street 2:SUITE #310
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-682-4041
Mailing Address - Fax:541-682-2455
Practice Address - Street 1:151 W 7TH AVE
Practice Address - Street 2:SUITE #310
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-682-4041
Practice Address - Fax:541-682-2455
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106650172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker