Healthcare Provider Details

I. General information

NPI: 1336363290
Provider Name (Legal Business Name): BENJAMIN JASON ROGOWAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE BUILDING B, SUITE 301
VANCOUVER WA
98664-1989
US

IV. Provider business mailing address

505 NE 87TH AVE BUILDING B, SUITE 301
VANCOUVER WA
98664-1989
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-1854
  • Fax:
Mailing address:
  • Phone: 360-514-1854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD60278948
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD60278948
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: