Provider Demographics
NPI:1023318771
Name:WRIGHT, ROGER LEWIS JR
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:LEWIS
Last Name:WRIGHT
Suffix:JR
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 1:6904 E 143RD ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-4126
Mailing Address - Country:US
Mailing Address - Phone:816-695-0986
Mailing Address - Fax:
Practice Address - Street 1:6904 E 143RD ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-4126
Practice Address - Country:US
Practice Address - Phone:816-695-0986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT125048001172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker