Healthcare Provider Details

I. General information

NPI: 1417017229
Provider Name (Legal Business Name): WAYNE R CONRAD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 4TH AVE S
SEATTLE WA
98134-2311
US

IV. Provider business mailing address

4401 4TH AVE S
SEATTLE WA
98134-2311
US

V. Phone/Fax

Practice location:
  • Phone: 206-464-7916
  • Fax:
Mailing address:
  • Phone: 206-464-7916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTX 1208
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: