Provider Demographics
NPI:1174997290
Name:BONGAR, CONNIE ELA LUPE JOY BILLONES (AGNP)
Entity type:Individual
Prefix:
First Name:CONNIE ELA LUPE JOY
Middle Name:BILLONES
Last Name:BONGAR
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2686 PATTERSON RD
Mailing Address - Street 2:SMMG PHYS MED & REHAB
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8817
Mailing Address - Country:US
Mailing Address - Phone:970-298-6005
Mailing Address - Fax:970-298-7138
Practice Address - Street 1:2686 PATTERSON RD
Practice Address - Street 2:SMMG PHYS MED & REHAB
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8817
Practice Address - Country:US
Practice Address - Phone:970-298-6005
Practice Address - Fax:970-298-7138
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0991782363LA2200X
COAPN.0991782-NP363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology