Provider Demographics
NPI:1477757417
Name:ROGERS, RICHARD ALAN JR (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:ROGERS
Suffix:JR
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 1:811 13TH ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2700
Mailing Address - Country:US
Mailing Address - Phone:706-722-3401
Mailing Address - Fax:706-724-6540
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCFMWMedicare ID - Type UnspecifiedMEDICARE PROVIDER
GAQ17291Medicare UPIN