Provider Demographics
NPI:1982160990
Name:RONGEY, NICKOLAS (AGNP-C)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:
Last Name:RONGEY
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 CARRIAGE HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-6800
Mailing Address - Country:US
Mailing Address - Phone:636-484-3170
Mailing Address - Fax:
Practice Address - Street 1:3550 MCKELVEY RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2527
Practice Address - Country:US
Practice Address - Phone:314-741-0911
Practice Address - Fax:314-741-0501
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020503363L00000X
MO2018040228363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420066868Medicaid