Provider Demographics
NPI:1205028768
Name:CONDADO, CARLOS (CRNA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CONDADO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 CROOKED VINE CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2090
Mailing Address - Country:US
Mailing Address - Phone:715-490-2186
Mailing Address - Fax:
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-445-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI160332367500000X
WI3967-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44350400Medicaid
WI44350400Medicaid