Provider Demographics
NPI:1467487728
Name:RUTLEDGE, ROGER WAYNE (FNP)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:WAYNE
Last Name:RUTLEDGE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 THORN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:LA
Mailing Address - Zip Code:71225
Mailing Address - Country:US
Mailing Address - Phone:318-644-1501
Mailing Address - Fax:
Practice Address - Street 1:5328 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7506
Practice Address - Country:US
Practice Address - Phone:318-397-3636
Practice Address - Fax:318-397-3639
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN073699363L00000X
LAAP03572363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1567591Medicaid
P03498Medicare UPIN
LA1567591Medicaid