Basic Information
Provider Information | |||||||||
NPI: | 1063502706 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONARD | ||||||||
FirstName: | KATRINA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | CORPORATE CREDENTIALING | ||||||||
Address2: | P.O. BOX 269 | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 19899 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026515938 | ||||||||
FaxNumber: | 3026516077 | ||||||||
Practice Location | |||||||||
Address1: | A.I. DUPONT HOSPITAL FOR CHILDREN | ||||||||
Address2: | 1600 ROCKLAND ROAD | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 19803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026514000 | ||||||||
FaxNumber: | 3026514945 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | C10002975 | DE | X |   | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0213X | C10002975 | DE | X |   | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
ID | Type | State | Issuer | Description | 1622130 (PA) | 05 | DE |   | MEDICAID |