Basic Information
| Provider Information | |||||||||
| NPI: | 1033153036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 218 | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740160218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188553737 | ||||||||
| FaxNumber: | 9183418139 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 E BLUE STARR DR | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740174223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183418100 | ||||||||
| FaxNumber: | 9183418139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 02/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1737 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 200193550A | 05 | OK | MEDICAID |