Provider Demographics
NPI:1013901495
Name:KONRAD, PATRICIA NOVECK (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:NOVECK
Last Name:KONRAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 BLUMENSCHEIN RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6378
Mailing Address - Country:US
Mailing Address - Phone:505-758-7876
Mailing Address - Fax:
Practice Address - Street 1:1316 BLUMENSCHEIN RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6378
Practice Address - Country:US
Practice Address - Phone:505-758-7876
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20020061207ZP0101X
CAA22569207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM891059UMedicaid
NM891059UMedicaid