Provider Demographics
NPI:1598733172
Name:ROGERS, GLEN M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:M
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY STE 617
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4319
Practice Address - Country:US
Practice Address - Phone:206-623-0922
Practice Address - Fax:206-623-1588
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60299909363A00000X, 363AS0400X, 363AS0400X
CAPA18071363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023881Medicaid