Provider Demographics
NPI:1245341874
Name:ROGERS, TRACY EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:EDWARD
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CONWAY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3153
Mailing Address - Country:US
Mailing Address - Phone:406-751-4189
Mailing Address - Fax:406-751-4145
Practice Address - Street 1:202 CONWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3153
Practice Address - Country:US
Practice Address - Phone:406-751-4189
Practice Address - Fax:406-751-4145
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT441363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4307613Medicaid
MT000097043OtherBLUE CROSS
MT4307613Medicaid
MT000097043OtherBLUE CROSS