Provider Demographics
NPI:1629047949
Name:CONRAD, SUSAN MARIA (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIA
Last Name:CONRAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:KROL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1105 SCHROCK RD
Mailing Address - Street 2:200
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1146
Mailing Address - Country:US
Mailing Address - Phone:614-505-7633
Mailing Address - Fax:614-847-1106
Practice Address - Street 1:1105 SCHROCK RD
Practice Address - Street 2:200
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1146
Practice Address - Country:US
Practice Address - Phone:614-505-7633
Practice Address - Fax:614-847-1106
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291083700Medicaid
OH9358461OtherMCR GROUP
FL291083700Medicaid