Provider Demographics
NPI:1477680635
Name:SWANSON, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:VEGUITA
Mailing Address - State:NM
Mailing Address - Zip Code:87062-0568
Mailing Address - Country:US
Mailing Address - Phone:505-459-5607
Mailing Address - Fax:505-861-3023
Practice Address - Street 1:325 E SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002
Practice Address - Country:US
Practice Address - Phone:505-459-5607
Practice Address - Fax:505-861-3023
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5439174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist