Basic Information
| Provider Information | |||||||||
| NPI: | 1184690760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONDON | ||||||||
| FirstName: | MYRTH | ||||||||
| MiddleName: | CRYSTAL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHERRATT | ||||||||
| OtherFirstName: | MYRTH | ||||||||
| OtherMiddleName: | CRYSTAL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 622W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874614 | ||||||||
| FaxNumber: | 9063874727 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 SANDPOINT RD | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874110 | ||||||||
| FaxNumber: | 9063872825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704173840 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 4704173840 | 01 | MI | STATE LICENSE | OTHER |