Healthcare Provider Details

I. General information

NPI: 1275150047
Provider Name (Legal Business Name): ROGER MARK BOOTH JR. APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2020
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SPRING VALLEY DR
HUNTINGTON WV
25704-9501
US

IV. Provider business mailing address

1540 SPRING VALLEY DR
HUNTINGTON WV
25704-9501
US

V. Phone/Fax

Practice location:
  • Phone: 304-429-6741
  • Fax: 215-842-4233
Mailing address:
  • Phone: 304-429-6741
  • Fax: 215-842-4233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number105246
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: