1548396096 NPI number — ROY KENT ROGERS PA-C

Table of content: ROY KENT ROGERS PA-C (NPI 1548396096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548396096 NPI number — ROY KENT ROGERS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROGERS
Provider First Name:
ROY
Provider Middle Name:
KENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548396096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5012 S US HIGHWAY 75 STE 300
Provider Second Line Business Mailing Address:
ATTN: BILLING
Provider Business Mailing Address City Name:
DENISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75020-4589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-920-2273
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1807 W UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74701-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-920-2273
Provider Business Practice Location Address Fax Number:
580-920-9978
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA02240 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 812 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100132370A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 343050601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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