Basic Information
| Provider Information | |||||||||
| NPI: | 1316284813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONANT | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | HE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELGADO | ||||||||
| OtherFirstName: | JUAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4004 BEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN YSIDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921732007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4004 BEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN YSIDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921732007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2013 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | Other Service Providers | Health Educator |
No ID Information.