Provider Demographics
NPI:1043582422
Name:CONRAD, JOHN CHRISTIAN JR (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHRISTIAN
Last Name:CONRAD
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4064 POSTAL DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6438
Mailing Address - Country:US
Mailing Address - Phone:540-725-1226
Mailing Address - Fax:540-857-5306
Practice Address - Street 1:4064 POSTAL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6438
Practice Address - Country:US
Practice Address - Phone:540-725-1226
Practice Address - Fax:540-857-5306
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003758363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1043582422OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA1043582422OtherOPTIMA HEALTH PLAN
VA1043582422OtherINTOTAL
VA1043582422OtherHUMANA MEDICARE
VA1043582422OtherAETNA
VA540506332115OtherTRICARE/CHAMPUS
VA1043582422OtherANTHEM MEDIGAP
VAP01072820OtherRAILROAD MEDICARE
VA1043582422OtherMEDICAID QMB
VA1043582422OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY