Provider Demographics
NPI:1275150047
Name:BOOTH, ROGER MARK JR (NP-C)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:MARK
Last Name:BOOTH
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 SPRING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-9501
Mailing Address - Country:US
Mailing Address - Phone:304-654-4035
Mailing Address - Fax:
Practice Address - Street 1:1540 SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9501
Practice Address - Country:US
Practice Address - Phone:304-654-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-28
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV105246363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology