Provider Demographics
NPI:1104469477
Name:O'CONNELL, KEVIN WILLIAM
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILLIAM
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1817
Mailing Address - Country:US
Mailing Address - Phone:860-930-3053
Mailing Address - Fax:
Practice Address - Street 1:325 CEDAR RIDGE DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1817
Practice Address - Country:US
Practice Address - Phone:860-930-3053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-19
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant