Provider Demographics
NPI:1811549645
Name:DUNCKER, CONRAD ORRMAL
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:ORRMAL
Last Name:DUNCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 W FILLMORE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-0027
Mailing Address - Country:US
Mailing Address - Phone:224-522-8785
Mailing Address - Fax:312-942-3113
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-5000
Practice Address - Fax:312-942-3113
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019350363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health