Healthcare Provider Details

I. General information

NPI: 1689780843
Provider Name (Legal Business Name): ANNETTE CONRAD MPA, MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST
RIVERSIDE CA
92503-3901
US

IV. Provider business mailing address

29198 STONEGATE LN
HIGHLAND CA
92346-5866
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-2092
  • Fax: 951-352-1913
Mailing address:
  • Phone: 909-864-4747
  • Fax: 909-864-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT13244
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: