Provider Demographics
NPI:1083830103
Name:ROGERS, MATTHEW JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84964
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-4964
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:907-459-3978
Practice Address - Street 1:1408 19TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5903
Practice Address - Country:US
Practice Address - Phone:907-452-8251
Practice Address - Fax:907-459-3878
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant