Provider Demographics
NPI:1669426417
Name:ROGERS, ROBERT JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
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 1:1500 CONTINENTAL PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-4105
Mailing Address - Country:US
Mailing Address - Phone:360-424-7041
Mailing Address - Fax:360-424-8449
Practice Address - Street 1:1500 CONTINENTAL PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4105
Practice Address - Country:US
Practice Address - Phone:360-424-7041
Practice Address - Fax:360-424-8449
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004957363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0203803OtherDEPT. L&I
WA8441693Medicaid
WA0203803OtherDEPT. L&I
WA8441693Medicaid