Provider Demographics
NPI:1679216337
Name:BERRY, CONNOR (PA-C)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:BERRY
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 1:676 N SAINT CLAIR ST STE 650
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2929
Mailing Address - Country:US
Mailing Address - Phone:312-695-3800
Mailing Address - Fax:312-695-3644
Practice Address - Street 1:676 N SAINT CLAIR ST STE 650
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2929
Practice Address - Country:US
Practice Address - Phone:312-695-3800
Practice Address - Fax:312-695-3644
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085008961363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical