Provider Demographics
NPI:1306856562
Name:ROG, MEGAN E (PAC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:E
Last Name:ROG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BRYAN RD STE 5
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5340
Mailing Address - Country:US
Mailing Address - Phone:813-689-2054
Mailing Address - Fax:813-654-5640
Practice Address - Street 1:305 BRYAN RD STE 5
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5340
Practice Address - Country:US
Practice Address - Phone:813-689-2054
Practice Address - Fax:813-654-5640
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7138ZMedicare ID - Type Unspecified
P54193Medicare UPIN