Provider Demographics
NPI:1487219317
Name:CONANT, ROGER ALBERT
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALBERT
Last Name:CONANT
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-579-3203
Mailing Address - Fax:
Practice Address - Street 1:8041 N BLACK CANYON HWY STE I
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4173
Practice Address - Country:US
Practice Address - Phone:602-249-0115
Practice Address - Fax:602-249-0837
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ226870363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health