Provider Demographics
NPI:1043433014
Name:CONRAD, KRISTIE (PA)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:
Other - Last Name:FIZZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:
Practice Address - Street 1:14351 KUTZTOWN RD
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522-9273
Practice Address - Country:US
Practice Address - Phone:610-944-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant