Healthcare Provider Details

I. General information

NPI: 1528993250
Provider Name (Legal Business Name): CONRAD WALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W 10TH ST STE 100
SEDALIA MO
65301-2540
US

IV. Provider business mailing address

147 SYCAMORE ST
PIKEVILLE KY
41501-9118
US

V. Phone/Fax

Practice location:
  • Phone: 660-827-2883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2026039109
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: