Provider Demographics
NPI:1962425322
Name:OCONNOR, CAROLYN A
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:OCONNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 MEMORIAL ST
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1524
Mailing Address - Country:US
Mailing Address - Phone:509-786-2222
Mailing Address - Fax:509-786-6612
Practice Address - Street 1:336 CHARDONNAY AVE STE A
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-9515
Practice Address - Country:US
Practice Address - Phone:509-786-1576
Practice Address - Fax:509-786-1574
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8214892Medicaid
WAG8903861Medicare PIN
WA8214892Medicaid