Provider Demographics
NPI:1689780843
Name:CONRAD, ANNETTE (MPA, MPT)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MPA, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29198 STONEGATE LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-5866
Mailing Address - Country:US
Mailing Address - Phone:909-864-4747
Mailing Address - Fax:909-864-4747
Practice Address - Street 1:3975 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3901
Practice Address - Country:US
Practice Address - Phone:951-352-2092
Practice Address - Fax:951-352-1913
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13244225100000X
CAPA20557363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist