Provider Demographics
NPI:1285607820
Name:CONNOLLY, BEVERLY D (PA C)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:D
Last Name:CONNOLLY
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 1:26218 US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-1707
Mailing Address - Country:US
Mailing Address - Phone:352-350-5230
Mailing Address - Fax:
Practice Address - Street 1:26218 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-1707
Practice Address - Country:US
Practice Address - Phone:352-350-5230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9107812363A00000X
GA6136363A00000X
NC0010-01476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P22337Medicare UPIN
CO44683Medicare PIN