Basic Information
| Provider Information | |||||||||
| NPI: | 1043596588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGEL | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRICKWOOD | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 270 E. STATE ST. | ||||||||
| Address2: | STE. 240 | ||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446014369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305966560 | ||||||||
| FaxNumber: | 3305966575 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 E. STATE ST. | ||||||||
| Address2: | STE. 240 | ||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446014369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305966560 | ||||||||
| FaxNumber: | 3305966575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3382 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50-003382 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0122854 | 05 | OH | MEDICAID |