Basic Information
| Provider Information | |||||||||
| NPI: | 1134199532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | GERARD | ||||||||
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| Credential: | PA-C, MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 HUEBNER RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664424030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852397863 | ||||||||
| FaxNumber: | 7852408203 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 HUEBNER RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664424030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852407652 | ||||||||
| FaxNumber: | 7852408351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 15-01618 | KS | N | Allopathic & Osteopathic Physicians | General Practice | 363AM0700X | 15-01618 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1134199532 | 01 | NPI | OTHER |