Provider Demographics
NPI:1245481951
Name:SHAKER, CONRAD (RN)
Entity type:Individual
Prefix:MR
First Name:CONRAD
Middle Name:
Last Name:SHAKER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 352
Mailing Address - Street 2:
Mailing Address - City:LA VALLE
Mailing Address - State:WI
Mailing Address - Zip Code:53941-0352
Mailing Address - Country:US
Mailing Address - Phone:608-415-1696
Mailing Address - Fax:
Practice Address - Street 1:110 S EAST ST
Practice Address - Street 2:
Practice Address - City:LA VALLE
Practice Address - State:WI
Practice Address - Zip Code:53941-8525
Practice Address - Country:US
Practice Address - Phone:608-415-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152058163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35011300Medicaid