Provider Demographics
NPI:1710055165
Name:ROGERS, NICHOLETTE (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLETTE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 METROHEALTH DR
Mailing Address - Street 2:MHMC-MEDICINE-GASTROENTEROLOGY
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1900
Mailing Address - Country:US
Mailing Address - Phone:216-778-2039
Mailing Address - Fax:
Practice Address - Street 1:2500 METROHEALTH DR
Practice Address - Street 2:MHMC-MEDICINE-GASTROENTEROLOGY
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1900
Practice Address - Country:US
Practice Address - Phone:216-778-2039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH28052642600OtherBWC
OHP33126Medicare UPIN
OH28052642600OtherBWC