Basic Information
| Provider Information | |||||||||
| NPI: | 1619084647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONDER | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | MCCORKLE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048874530 | ||||||||
| FaxNumber: | 7048874531 | ||||||||
| Practice Location | |||||||||
| Address1: | 10030 GILEAD RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048874530 | ||||||||
| FaxNumber: | 7048874531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 0050-00682 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 1-130234 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 5000682 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7003749 | 05 | NC | MEDICAID | P00297346 | 01 | RAILROAD MEDICARE | OTHER | 05673386 | 05 | MS | MEDICAID | Q53832 | 01 | AL | VIVA | OTHER | NP0911 | 05 | SC | MEDICAID | 130679 | 05 | AL | MEDICAID | 051118877 | 01 | AL | BCBS | OTHER |