=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689780843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE CONRAD MPA, MPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 10/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3975 JACKSON ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-352-2092
-----------------------------------------------------
Fax | 951-352-1913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29198 STONEGATE LN
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92346-5866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-864-4747
-----------------------------------------------------
Fax | 909-864-4747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT13244
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA20557
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------