Provider Demographics
NPI:1851084768
Name:CONNER, TYSHAWN (LDO)
Entity Type:Individual
Prefix:
First Name:TYSHAWN
Middle Name:
Last Name:CONNER
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 BOOTH RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-3422
Mailing Address - Country:US
Mailing Address - Phone:478-918-0636
Mailing Address - Fax:478-918-0683
Practice Address - Street 1:502 BOOTH RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3422
Practice Address - Country:US
Practice Address - Phone:478-918-0636
Practice Address - Fax:478-918-0683
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002698156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician