Provider Demographics
NPI:1679279012
Name:LEWELLEN, CONNOR
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:LEWELLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7243 DELLA DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5104
Mailing Address - Country:US
Mailing Address - Phone:321-842-5851
Mailing Address - Fax:321-842-0089
Practice Address - Street 1:7243 DELLA DR FL 3
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5104
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:321-842-0089
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9117576363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program