Basic Information
| Provider Information | |||||||||
| NPI: | 1124325907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | WILLARD | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 OLD ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | SAINT ROBERT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655843730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733365100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 441 W ELM ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655363523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175322890 | ||||||||
| FaxNumber: | 4175322965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2011 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2011003943 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 220026034 | 05 | MO | MEDICAID |