Healthcare Provider Details

I. General information

NPI: 1609792696
Provider Name (Legal Business Name): CHARLES CONDUAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 BIRCH ST
SAINT PAUL MN
55115-1603
US

IV. Provider business mailing address

84 BIRCH ST
SAINT PAUL MN
55115-1603
US

V. Phone/Fax

Practice location:
  • Phone: 218-329-5080
  • Fax: 218-329-5080
Mailing address:
  • Phone: 218-329-5080
  • Fax: 218-329-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0205X
TaxonomyRadiological Physics Physician
License Number000815
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: