Healthcare Provider Details

I. General information

NPI: 1700714102
Provider Name (Legal Business Name): GRACE ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3232 N BALLARD RD
APPLETON WI
54911-0003
US

IV. Provider business mailing address

13440 NEVADA AVE
SAVAGE MN
55378-3214
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-7105
  • Fax:
Mailing address:
  • Phone: 612-889-5497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: