Provider Demographics
NPI:1013121474
Name:CONNOLLY, EUGENE MARK (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:MARK
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:MARK
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPA C
Mailing Address - Street 1:57 HAMPTON RD
Mailing Address - Street 2:STE 201
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-4973
Mailing Address - Country:US
Mailing Address - Phone:631-283-1126
Mailing Address - Fax:631-283-7496
Practice Address - Street 1:518 MONTAUK HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:AMAGANSETT
Practice Address - State:NY
Practice Address - Zip Code:11930-2110
Practice Address - Country:US
Practice Address - Phone:631-267-5373
Practice Address - Fax:631-267-5376
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical