Basic Information
| Provider Information | |||||||||
| NPI: | 1851383236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILBERT | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10930 N TATUM BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022637600 | ||||||||
| FaxNumber: | 6022120365 | ||||||||
| Practice Location | |||||||||
| Address1: | 10930 N TATUM BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022637600 | ||||||||
| FaxNumber: | 6022120365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 3209 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3209 | 01 | AZ | AZ LICENSE | OTHER | 961111 | 05 | AZ | MEDICAID |