Healthcare Provider Details

I. General information

NPI: 1902724586
Provider Name (Legal Business Name): ROGER PACKARD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 MEDICAL CENTER DR
ROCKVILLE MD
20850-6361
US

IV. Provider business mailing address

7985 MARTOWN RD
LAUREL MD
20723-1147
US

V. Phone/Fax

Practice location:
  • Phone: 124-086-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2132728
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: