Basic Information
| Provider Information | |||||||||
| NPI: | 1730152703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONGER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 25645 | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028775199 | ||||||||
| FaxNumber: | 7029845194 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 W OAKEY BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028775199 | ||||||||
| FaxNumber: | 7029845184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 762 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | V113510 | 01 | NV | MEDICARE SMA | OTHER | 002019697 | 05 | NV | MEDICAID |