Healthcare Provider Details

I. General information

NPI: 1073926390
Provider Name (Legal Business Name): WYATT ROGERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 TONGASS DR
SITKA AK
99835-9416
US

IV. Provider business mailing address

PO BOX 528 ATTN:BH SOBERING CENTER
BETHEL AK
99559-0528
US

V. Phone/Fax

Practice location:
  • Phone: 907-966-2411
  • Fax: 907-966-8383
Mailing address:
  • Phone: 907-543-6830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License NumberNURR38294
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: