Provider Demographics
NPI:1578217626
Name:BARRETTA, CONNOR MICHAEL
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:MICHAEL
Last Name:BARRETTA
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 1:9320 US HIGHWAY 301 S
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-6300
Mailing Address - Country:US
Mailing Address - Phone:813-471-0000
Mailing Address - Fax:
Practice Address - Street 1:9320 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-6300
Practice Address - Country:US
Practice Address - Phone:813-471-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9378325163W00000X
FLAPRN11019546367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse