Healthcare Provider Details

I. General information

NPI: 1205028768
Provider Name (Legal Business Name): CARLOS X CONDADO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9576 HIGHWAY 70
MINOCQUA WI
54548-9067
US

IV. Provider business mailing address

9576 HWY 70
MINOCQUA WI
54548-9067
US

V. Phone/Fax

Practice location:
  • Phone: 715-358-1000
  • Fax:
Mailing address:
  • Phone: 715-358-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number160332
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3967-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: