Provider Demographics
NPI:1891165924
Name:ROGERS, TYLAN
Entity Type:Individual
Prefix:
First Name:TYLAN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 K ST NE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1746
Mailing Address - Country:US
Mailing Address - Phone:808-359-3145
Mailing Address - Fax:
Practice Address - Street 1:28 K ST NE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-1746
Practice Address - Country:US
Practice Address - Phone:808-359-3145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1129014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant