Provider Demographics
NPI:1770261513
Name:WOODS, ROGER DERRICK (PA-C)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DERRICK
Last Name:WOODS
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:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MT
Mailing Address - Zip Code:59327-0268
Mailing Address - Country:US
Mailing Address - Phone:423-364-6377
Mailing Address - Fax:
Practice Address - Street 1:383 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:MT
Practice Address - Zip Code:59327-7971
Practice Address - Country:US
Practice Address - Phone:406-346-2161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-128126363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical