Provider Demographics
NPI:1992316525
Name:PASSALACQUA, CONNOR GEORGE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:GEORGE
Last Name:PASSALACQUA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8720 AITKEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-2606
Mailing Address - Country:US
Mailing Address - Phone:315-507-0762
Mailing Address - Fax:
Practice Address - Street 1:130 LOMOND CT STE 1
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5951
Practice Address - Country:US
Practice Address - Phone:315-724-4286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist