Provider Demographics
NPI:1316517105
Name:ROBERTSON, CONNER
Entity type:Individual
Prefix:
First Name:CONNER
Middle Name:
Last Name:ROBERTSON
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 1:7903 W GRANDRIDGE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7827
Mailing Address - Country:US
Mailing Address - Phone:509-783-0667
Mailing Address - Fax:
Practice Address - Street 1:7903 W GRANDRIDGE BLVD STE A
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7827
Practice Address - Country:US
Practice Address - Phone:509-783-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61169272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist