Provider Demographics
NPI:1164492666
Name:ROGERS, SUSAN GAYLE (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAYLE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SUMMITVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2715
Mailing Address - Country:US
Mailing Address - Phone:509-248-7849
Mailing Address - Fax:509-248-2891
Practice Address - Street 1:1607 CREEKSIDE LOOP
Practice Address - Street 2:STE. 100
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4882
Practice Address - Country:US
Practice Address - Phone:509-453-4614
Practice Address - Fax:509-225-2712
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006312163WG0000X, 363L00000X
WARN00129267163WM0705X, 163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA614161500OtherDOL OWCP FECA
WA9642661Medicaid
WA0173362OtherL&I
WA9642661Medicaid
WAGAB36314Medicare PIN