Healthcare Provider Details

I. General information

NPI: 1619806080
Provider Name (Legal Business Name): MICHAEL ISAAC CONRAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 LYNWOOD CIR
CORONA CA
92881-7448
US

IV. Provider business mailing address

1951 LYNWOOD CIR
CORONA CA
92881-7448
US

V. Phone/Fax

Practice location:
  • Phone: 951-751-3605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95039039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: