Healthcare Provider Details

I. General information

NPI: 1548396096
Provider Name (Legal Business Name): ROY KENT ROGERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 W UNIVERSITY BLVD
DURANT OK
74701-3011
US

IV. Provider business mailing address

5012 S US HIGHWAY 75 STE 300 ATTN: BILLING
DENISON TX
75020-4589
US

V. Phone/Fax

Practice location:
  • Phone: 580-920-2273
  • Fax: 580-920-9978
Mailing address:
  • Phone: 580-920-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02240
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number812
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: