Basic Information
| Provider Information | |||||||||
| NPI: | 1982160990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RONGEY | ||||||||
| FirstName: | NICKOLAS | ||||||||
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| Credential: | AGNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 CARRIAGE HOUSE LN | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633766800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364843170 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3550 MCKELVEY RD | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147410911 | ||||||||
| FaxNumber: | 3147410501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2019 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209020503 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 2018040228 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 420066868 | 05 | MO | MEDICAID |