Provider Demographics
NPI:1790947620
Name:KIRK, ROGER WAYNE JR (CRNP)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:WAYNE
Last Name:KIRK
Suffix:JR
Gender:M
Credentials:CRNP
Other - Prefix:
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Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:UNION SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36089-0312
Mailing Address - Country:US
Mailing Address - Phone:334-740-5252
Mailing Address - Fax:334-738-7339
Practice Address - Street 1:1340 HIGHWAY 231 S STE 1
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36081-3012
Practice Address - Country:US
Practice Address - Phone:334-770-7337
Practice Address - Fax:334-770-7339
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL1-079245363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics