Provider Demographics
NPI:1093185191
Name:ROGERS, STEPHEN (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
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 1:424 YELLOWSTONE AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9309
Mailing Address - Country:US
Mailing Address - Phone:307-527-7100
Mailing Address - Fax:307-527-7145
Practice Address - Street 1:424 YELLOWSTONE AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9309
Practice Address - Country:US
Practice Address - Phone:307-527-7100
Practice Address - Fax:307-527-7145
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT650363A00000X
MTMED-PAC-LIC-68103363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant