Provider Demographics
NPI:1689154478
Name:DECKER, ROGER L (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:DECKER
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PHYSICIANS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9569
Mailing Address - Country:US
Mailing Address - Phone:662-655-2136
Mailing Address - Fax:
Practice Address - Street 1:55 PHYSICIANS LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9569
Practice Address - Country:US
Practice Address - Phone:662-655-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24489363LA2100X
MS902736363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care