Provider Demographics
NPI:1285992487
Name:CONRAD, CARL JOHN
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:JOHN
Last Name:CONRAD
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 1:5515 S 299TH CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-2325
Mailing Address - Country:US
Mailing Address - Phone:253-249-3029
Mailing Address - Fax:
Practice Address - Street 1:3820 S 320TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-3115
Practice Address - Country:US
Practice Address - Phone:253-839-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60240935225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist