Provider Demographics
NPI:1659842557
Name:ROGERS, BLAKE AARON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:AARON
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 1:7878 RAWLEY PIKE
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:VA
Mailing Address - Zip Code:22831-2102
Mailing Address - Country:US
Mailing Address - Phone:540-476-2728
Mailing Address - Fax:
Practice Address - Street 1:2210 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1630
Practice Address - Country:US
Practice Address - Phone:434-575-5864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110006543363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty