Provider Demographics
NPI:1972554046
Name:CONNELLY, JAN STUART (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:STUART
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W CATALDO
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2217
Mailing Address - Country:US
Mailing Address - Phone:509-624-2326
Mailing Address - Fax:509-744-3040
Practice Address - Street 1:217 W CATALDO
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2217
Practice Address - Country:US
Practice Address - Phone:509-624-2326
Practice Address - Fax:509-744-3040
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000019284207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA99107OtherL & I
WA1784701Medicaid
WA99107OtherL & I
WA1784701Medicaid