Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 67035 | FL |
NPI | 1003897919 |
---|---|
Provider Name | Teresa L. Conrad |
First Address | Brandon, FL 33511-5700 |
Second Address | Brandon, FL 33511-5700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2005 |
Last Update Date | 29/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
376137100 | (05) | FL |
F90368 | (02) | FL |