Provider Demographics
NPI:1992774152
Name:CONNELLY, GERARD JOHN (PAC)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:JOHN
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3196 S MARYLAND PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109
Mailing Address - Country:US
Mailing Address - Phone:702-731-8099
Mailing Address - Fax:702-731-8292
Practice Address - Street 1:6900 N PECOS RD
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-4400
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA873363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504648Medicaid
AZ991530Medicaid
AZ991530Medicaid