Provider Demographics
NPI:1982762415
Name:ROGERS, WYGONDA KAY (NP)
Entity Type:Individual
Prefix:MS
First Name:WYGONDA
Middle Name:KAY
Last Name:ROGERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 MCINTYRE DR
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4221
Mailing Address - Country:US
Mailing Address - Phone:812-336-4947
Mailing Address - Fax:
Practice Address - Street 1:2920 MCINTYRE DR
Practice Address - Street 2:SUITE 305
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-336-4947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000905A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN548840IMedicare ID - Type Unspecified
INQ68107Medicare UPIN