Provider Demographics
NPI:1770812851
Name:CONRAD, SALLY L (PA-C)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:L
Last Name:CONRAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8884 SELBO PEAK PL NW
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-9456
Mailing Address - Country:US
Mailing Address - Phone:360-509-2612
Mailing Address - Fax:
Practice Address - Street 1:20730 BOND RD NE STE 205
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9000
Practice Address - Country:US
Practice Address - Phone:360-779-9727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003503363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical