Basic Information
| Provider Information | |||||||||
| NPI: | 1962671412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | NICKI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238692 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7431 NW EVERGREEN PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037343700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 546766 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 363LW0102X | 201408658NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 546766 | 01 | CA | MEDICAL LICENSE | OTHER | 500704873 | 05 | OR | MEDICAID |