Basic Information
| Provider Information | |||||||||
| NPI: | 1356636385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | SETH | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742616 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702198420 | ||||||||
| FaxNumber: | 7702198440 | ||||||||
| Practice Location | |||||||||
| Address1: | 743 SPRING ST NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702199000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-04889 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 006176 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1356636385 | 05 | NC | MEDICAID | 1897PA | 05 | SC | MEDICAID |