Provider Demographics
NPI:1225407539
Name:O'CONNOR, KEVIN MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MATTHEW
Last Name:O'CONNOR
Suffix:
Gender:M
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 1:509 OLDE WATERFORD WAY
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4125
Mailing Address - Country:US
Mailing Address - Phone:704-293-8836
Mailing Address - Fax:
Practice Address - Street 1:509 OLDE WATERFORD WAY
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4125
Practice Address - Country:US
Practice Address - Phone:704-293-8836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant