Provider Demographics
NPI:1518908078
Name:ROGERS, THERESA LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LYNN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:LYNN
Other - Last Name:MCCLURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6465 S YALE AVE STE 910
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7811
Practice Address - Country:US
Practice Address - Phone:918-502-3200
Practice Address - Fax:918-502-3205
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100131930AMedicaid
OK100131930AMedicaid