Provider Demographics
NPI:1588484950
Name:DEICHMAN, CONNER LEE (PHD TRACK)
Entity type:Individual
Prefix:
First Name:CONNER
Middle Name:LEE
Last Name:DEICHMAN
Suffix:
Gender:M
Credentials:PHD TRACK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 N 100 W APT 7
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1668
Mailing Address - Country:US
Mailing Address - Phone:385-625-6476
Mailing Address - Fax:
Practice Address - Street 1:589 S STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5056
Practice Address - Country:US
Practice Address - Phone:801-855-0124
Practice Address - Fax:801-429-2001
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program