Healthcare Provider Details

I. General information

NPI: 1518544337
Provider Name (Legal Business Name): BRENT LOGAN CONRAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W FAIRVIEW ST
COLFAX WA
99111-9552
US

IV. Provider business mailing address

1200 W FAIRVIEW ST
COLFAX WA
99111-9552
US

V. Phone/Fax

Practice location:
  • Phone: 509-397-4717
  • Fax: 509-397-3501
Mailing address:
  • Phone: 509-397-3435
  • Fax: 509-397-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61573658
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: