Provider Demographics
NPI:1942459870
Name:MCCONNELL, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:MCCONNELL
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 1:212 W DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:POND CREEK
Mailing Address - State:OK
Mailing Address - Zip Code:73766-9783
Mailing Address - Country:US
Mailing Address - Phone:580-231-5070
Mailing Address - Fax:
Practice Address - Street 1:212 W DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:POND CREEK
Practice Address - State:OK
Practice Address - Zip Code:73766-9783
Practice Address - Country:US
Practice Address - Phone:580-231-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program