Healthcare Provider Details

I. General information

NPI: 1245341874
Provider Name (Legal Business Name): TRACY EDWARD ROGERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CONWAY DR STE 200
KALISPELL MT
59901-3153
US

IV. Provider business mailing address

202 CONWAY DR STE 200
KALISPELL MT
59901-3153
US

V. Phone/Fax

Practice location:
  • Phone: 406-751-4189
  • Fax: 406-751-4145
Mailing address:
  • Phone: 406-751-4189
  • Fax: 406-751-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number441
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: