Provider Demographics
NPI:1821896085
Name:MANDA, CONNOR FAWKES
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:FAWKES
Last Name:MANDA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1370
Mailing Address - Country:US
Mailing Address - Phone:612-408-7733
Mailing Address - Fax:763-292-5653
Practice Address - Street 1:2800 FREEWAY BLVD STE 204
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-1751
Practice Address - Country:US
Practice Address - Phone:763-412-1996
Practice Address - Fax:763-292-5653
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator