Provider Demographics
NPI:1558857920
Name:ROGERS, KEGAN DAVIS
Entity Type:Individual
Prefix:
First Name:KEGAN
Middle Name:DAVIS
Last Name:ROGERS
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 1:11441 S FRANCIS RD
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 E WARWICK DR STE 3
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1083
Practice Address - Country:US
Practice Address - Phone:894-636-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006867363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical