Provider Demographics
NPI:1790774354
Name:ROGERS, CAROL M (CONP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:ROGERS
Suffix:
Gender:F
Credentials:CONP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HARRISON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2161
Mailing Address - Country:US
Mailing Address - Phone:607-763-6850
Mailing Address - Fax:607-763-6703
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2161
Practice Address - Country:US
Practice Address - Phone:607-763-6850
Practice Address - Fax:607-763-6703
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3700121363L00000X
NYF3301131363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02204277Medicaid
NYCC8933Medicare ID - Type Unspecified
NY02204277Medicaid