Provider Demographics
NPI:1376978809
Name:ROGERS, CAITLIN MARY
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARY
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 E 12 MILE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3487
Mailing Address - Country:US
Mailing Address - Phone:586-261-1960
Mailing Address - Fax:
Practice Address - Street 1:27472 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6688
Practice Address - Country:US
Practice Address - Phone:586-439-6257
Practice Address - Fax:586-439-6232
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant