Provider Demographics
NPI:1053457226
Name:ROGERS, SHANDA DESHA (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANDA
Middle Name:DESHA
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 MARTINBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5923
Mailing Address - Country:US
Mailing Address - Phone:870-931-0762
Mailing Address - Fax:
Practice Address - Street 1:1900 STILLWATER DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9119
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:870-932-3611
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y298OtherARBCBS
AR142528721Medicaid