Provider Demographics
NPI:1952058125
Name:GWINN, CONNOR KENNETH
Entity Type:Individual
Prefix:MR
First Name:CONNOR
Middle Name:KENNETH
Last Name:GWINN
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 1:225 HASTINGS ST NE APT 309
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1526
Mailing Address - Country:US
Mailing Address - Phone:586-907-1316
Mailing Address - Fax:
Practice Address - Street 1:15 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2509
Practice Address - Country:US
Practice Address - Phone:616-233-1678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program