Provider Demographics
NPI:1720422645
Name:CONCANNON, NATALIE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:MARIE
Last Name:CONCANNON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:MARIE
Other - Last Name:GROME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 MOUNTAINVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-3444
Mailing Address - Country:US
Mailing Address - Phone:908-542-3000
Mailing Address - Fax:
Practice Address - Street 1:910 E 26TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-884-6300
Practice Address - Fax:612-884-6363
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00473600363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical