Provider Demographics
NPI:1619092418
Name:ROGERS, BRAD W (MSPT)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:W
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 BLUSTERY WAY
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8420
Mailing Address - Country:US
Mailing Address - Phone:501-329-6851
Mailing Address - Fax:
Practice Address - Street 1:150 SIEBENMORGAN RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4000
Practice Address - Country:US
Practice Address - Phone:501-329-6851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2479174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist