Provider Demographics
NPI:1740929306
Name:ROGERS, RYAN (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
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 1:1602 HUCKNALL PL
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2552
Mailing Address - Country:US
Mailing Address - Phone:912-601-7662
Mailing Address - Fax:
Practice Address - Street 1:1301 STATESBORO PLACE CIR # 1582
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2211
Practice Address - Country:US
Practice Address - Phone:912-500-2834
Practice Address - Fax:912-542-8200
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty