Healthcare Provider Details

I. General information

NPI: 1265298400
Provider Name (Legal Business Name): ROGUE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N PHOENIX RD STE 430
PHOENIX OR
97535-9108
US

IV. Provider business mailing address

205 N PHOENIX RD
PHOENIX OR
97535-9101
US

V. Phone/Fax

Practice location:
  • Phone: 541-778-4517
  • Fax: 541-833-0995
Mailing address:
  • Phone: 541-778-4517
  • Fax: 541-833-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: BEN DOUGLAS JOHNSON
Title or Position: OWNER
Credential: PA-C
Phone: 541-778-4517