Provider Demographics
NPI:1811323884
Name:CONNER, KATHRYN BLAIR (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BLAIR
Last Name:CONNER
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1483 TOBIAS GADSON BLVD STE 202
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-763-2320
Practice Address - Fax:843-763-4198
Is Sole Proprietor?:No
Enumeration Date:2013-09-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1970363AM0700X
SCPA 1970363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9223OtherROPER SAINT FRANCIS PHYSICIANS NETWORK GROUP PTAN
SCD043OtherGROUP MEDICARE PTAN
SC2004PAMedicaid
SC1902246077OtherARCIS HEALTHCARE GROUP NPI