Healthcare Provider Details

I. General information

NPI: 1063411734
Provider Name (Legal Business Name): RONALD R ROGERS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N DR MARTIN LUTHER KING JR BLVD
CLOVIS NM
88101-9412
US

IV. Provider business mailing address

1308 FAIRWAY TER
CLOVIS NM
88101-3037
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax: 573-686-2139
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR45276
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: