Provider Demographics
NPI:1699501965
Name:RATHSAM, CONNOR RYAN (PA-C)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:RYAN
Last Name:RATHSAM
Suffix:
Gender:M
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 1:170 N POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4132
Mailing Address - Country:US
Mailing Address - Phone:717-299-4871
Mailing Address - Fax:
Practice Address - Street 1:170 N POINTE BLVD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4132
Practice Address - Country:US
Practice Address - Phone:717-299-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA066007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant