Provider Demographics
NPI:1083741722
Name:ROGERS, RANDALL JAMES (PA-C, LMT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAMES
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PA-C, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JENNINGS AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6148
Mailing Address - Country:US
Mailing Address - Phone:352-357-5311
Mailing Address - Fax:352-357-0659
Practice Address - Street 1:601 JENNINGS AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6148
Practice Address - Country:US
Practice Address - Phone:352-357-5311
Practice Address - Fax:352-357-0659
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA58093225700000X
FLPA 9102164363AM0700X
FLPA9102164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA58093OtherSTATE OF FLORIDA LICENSE
FLPA 9102164OtherSTATE OF FLORIDA LICENSE