Provider Demographics
NPI:1093033821
Name:ROGERS, ABBY JAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:JAYNE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:
Other - Last Name:ONDARKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-267-7900
Mailing Address - Fax:616-267-7901
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 6100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-267-7900
Practice Address - Fax:616-267-7901
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32930423Medicare PIN