Healthcare Provider Details

I. General information

NPI: 1982178018
Provider Name (Legal Business Name): KENNETH JAMES ROEGER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 MEDICAL DISTRICT DR
DALLAS TX
75235-7701
US

IV. Provider business mailing address

1935 MEDICAL DISTRICT DR
DALLAS TX
75235-7701
US

V. Phone/Fax

Practice location:
  • Phone: 214-456-6393
  • Fax: 214-456-5587
Mailing address:
  • Phone: 214-456-6393
  • Fax: 214-456-5587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number836156
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP140339
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: