Healthcare Provider Details

I. General information

NPI: 1669019683
Provider Name (Legal Business Name): JUSTIN EARL ROGERS MSN, APRN, AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 WILLOW CREEK RD
PRESCOTT AZ
86301-1641
US

IV. Provider business mailing address

1210 HAISLEY RD
PRESCOTT AZ
86303-5379
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-5470
  • Fax:
Mailing address:
  • Phone: 928-899-8631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRNP235419
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: