Provider Demographics
NPI:1659338226
Name:CONRAD, SHANNON M (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:M
Last Name:CONRAD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:
Practice Address - Street 1:5070 INTERNATIONAL BLVD STE 131
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6007
Practice Address - Country:US
Practice Address - Phone:843-402-2995
Practice Address - Fax:843-402-3495
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1538207Q00000X
NY225835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC015389Medicaid
SC015389Medicaid
NYH72340Medicare UPIN
SCSC30632514Medicare UPIN
NY02309722Medicaid