Provider Demographics
NPI:1336115708
Name:CONNOR, ROSEMARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
Last Name:CONNOR
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 1:1095 NW SAINT LUCIE WEST BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1095 NW SAINT LUCIE WEST BLVD STE 106
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1719
Practice Address - Country:US
Practice Address - Phone:772-785-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2855363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08177511Medicaid
WY1003177247Medicaid
CO023958OtherKAISER COMMERCIAL NUMBER
CO023958OtherKAISER COMMERCIAL NUMBER
PA2855Medicare ID - Type Unspecified
COCOA105613Medicare PIN
Q03649Medicare UPIN
WY1003177247Medicaid