Provider Demographics
NPI:1558467852
Name:FOGG, ROGER M (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:M
Last Name:FOGG
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-8978
Mailing Address - Country:US
Mailing Address - Phone:541-862-2836
Mailing Address - Fax:541-862-2806
Practice Address - Street 1:8600 NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-8978
Practice Address - Country:US
Practice Address - Phone:541-862-2836
Practice Address - Fax:541-862-2806
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350113NP FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298515Medicaid
Q03683Medicare UPIN
OR298515Medicaid