Provider Demographics
NPI:1235538836
Name:WITHROW, JOHN CONRAD (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CONRAD
Last Name:WITHROW
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CONRAD
Other - Middle Name:
Other - Last Name:WITHROW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:207 BALFOUR DR
Mailing Address - Street 2:STE 102
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-3532
Mailing Address - Country:US
Mailing Address - Phone:336-875-8134
Mailing Address - Fax:
Practice Address - Street 1:207 BALFOUR DR
Practice Address - Street 2:STE 102
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-3532
Practice Address - Country:US
Practice Address - Phone:336-875-8134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPHYSICIAN-ERAS390200000X
NC246053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program