Provider Demographics
NPI:1083368856
Name:ROGERS, HAZEL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HAZEL
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:HAZEL
Other - Middle Name:
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2420 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3926
Mailing Address - Country:US
Mailing Address - Phone:305-607-2783
Mailing Address - Fax:
Practice Address - Street 1:2420 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3926
Practice Address - Country:US
Practice Address - Phone:320-253-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant