Provider Demographics
NPI:1043400419
Name:ROGERS, ANTONIA LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANTONIA
Middle Name:LYNN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:7777 B MILLIKEN AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-948-7590
Mailing Address - Fax:909-948-7290
Practice Address - Street 1:7777 MILLIKEN AVE STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6781
Practice Address - Country:US
Practice Address - Phone:909-948-7590
Practice Address - Fax:909-948-7290
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15561OtherSTATE LICENSE