Provider Demographics
NPI:1376523803
Name:ROGERS, COREY A (PA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:A
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 WEST VILLAGE CIRCLE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205
Mailing Address - Country:US
Mailing Address - Phone:316-838-2020
Mailing Address - Fax:316-838-7574
Practice Address - Street 1:7550 WEST VILLAGE CIRCLE
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205
Practice Address - Country:US
Practice Address - Phone:316-838-2020
Practice Address - Fax:316-838-7574
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100372330BMedicaid
KSP14659Medicare UPIN
KS100372330BMedicaid