Provider Demographics
NPI:1528833266
Name:SURGEON, CONNOR
Entity type:Individual
Prefix:MR
First Name:CONNOR
Middle Name:
Last Name:SURGEON
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 1:22 MUIRFIELD RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-0409
Mailing Address - Country:US
Mailing Address - Phone:636-675-9162
Mailing Address - Fax:
Practice Address - Street 1:2625 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3613
Practice Address - Country:US
Practice Address - Phone:314-347-8612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021012980225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist