Provider Demographics
NPI:1093080368
Name:CALVERT, ROGER WILLIAM JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:WILLIAM
Last Name:CALVERT
Suffix:JR
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 1:1105 SPRING ST
Mailing Address - Street 2:#202
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3527
Mailing Address - Country:US
Mailing Address - Phone:206-834-5899
Mailing Address - Fax:
Practice Address - Street 1:1105 SPRING ST
Practice Address - Street 2:#202
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3527
Practice Address - Country:US
Practice Address - Phone:206-834-5899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA602651123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant