Provider Demographics
NPI:1548289812
Name:CONRAD, TYLER R (DC)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:R
Last Name:CONRAD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:LILLY
Mailing Address - State:PA
Mailing Address - Zip Code:15938-0053
Mailing Address - Country:US
Mailing Address - Phone:814-886-9414
Mailing Address - Fax:814-886-9415
Practice Address - Street 1:520 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LILLY
Practice Address - State:PA
Practice Address - Zip Code:15938-1118
Practice Address - Country:US
Practice Address - Phone:814-886-9414
Practice Address - Fax:814-886-9415
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008957111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019523970001Medicaid
PA0019523970001Medicaid
PA095275Medicare UPIN