Provider Demographics
NPI:1770884421
Name:CONNOR, SUSAN MARIA (PA-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIA
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:7116 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2904
Practice Address - Country:US
Practice Address - Phone:443-577-0277
Practice Address - Fax:443-577-0288
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00565363A00000X
MDC0004772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISC85902Medicaid
MD149619Medicare PIN
RISC85902Medicaid
RI0022980Medicare PIN