Provider Demographics
NPI:1407880289
Name:SOUTHFORK ANESTHESIA PLLC
Entity Type:Organization
Organization Name:SOUTHFORK ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGLER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-599-2277
Mailing Address - Street 1:1907 E YANDELL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-3416
Mailing Address - Country:US
Mailing Address - Phone:915-219-4300
Mailing Address - Fax:915-519-4300
Practice Address - Street 1:1300 MURCHISON DR STE 200
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4838
Practice Address - Country:US
Practice Address - Phone:915-219-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX811186367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4306491Medicaid
MT4306491Medicaid