Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 11784 | OK |
Y | 207PE0004X | Emergency Medical Services | 11784 | OK |
N | 207Q00000X | Family Doctor | 11784 | OK |
NPI | 1144288911 |
---|---|
Provider Name | Mr. Gary D Conrad |
First Address | Guthrie, OK 73044-9562 |
Second Address | Midwest City, OK 73110-4201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2006 |
Last Update Date | 21/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100110920A | (05) | OK |
D38711 | (02) | OK |