Provider Demographics
NPI:1619084647
Name:CONDER, BEVERLY MCCORKLE (NP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:MCCORKLE
Last Name:CONDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-887-4530
Mailing Address - Fax:704-887-4531
Practice Address - Street 1:10030 GILEAD RD STE 201
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7545
Practice Address - Country:US
Practice Address - Phone:704-887-4530
Practice Address - Fax:704-887-4531
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-00682363LA2200X
AL1-130234363L00000X
NC5000682363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003749Medicaid
P00297346OtherRAILROAD MEDICARE
MS05673386Medicaid
ALQ53832OtherVIVA
SCNP0911Medicaid
AL130679Medicaid
AL051118877OtherBCBS
AL051118877OtherBCBS
AL102I509885Medicare PIN
NC7003749Medicaid
Q53832Medicare UPIN