Provider Demographics
NPI:1922716570
Name:CONNOR, LILY MACKENZIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LILY
Middle Name:MACKENZIE
Last Name:CONNOR
Suffix:
Gender:F
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 1:1335 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2536
Mailing Address - Country:US
Mailing Address - Phone:510-647-5101
Mailing Address - Fax:
Practice Address - Street 1:1335 STANFORD AVE
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2536
Practice Address - Country:US
Practice Address - Phone:510-647-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant