Provider Demographics
NPI:1114366895
Name:RODGERS, NICHOLAS MARK (CRNA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:MARK
Last Name:RODGERS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12225 28TH ST N
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1860
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-828-0723
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-2188
Practice Address - Fax:727-828-0723
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9282943367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH1751ZMedicare PIN