Provider Demographics
NPI:1205394608
Name:GONG, NATHANAEL JOHN
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:JOHN
Last Name:GONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 N TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-6367
Mailing Address - Country:US
Mailing Address - Phone:702-233-7000
Mailing Address - Fax:
Practice Address - Street 1:657 N TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6367
Practice Address - Country:US
Practice Address - Phone:702-233-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3320207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine