MEDICARE: MR. ROGER ALAN NEVLING PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2405	OK

General Provider Information

NPI Number	:	1225015027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER ALAN NEVLING PAC

Provider Business Mailing Address
First Line	:	350 S 40TH ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-4915
Country	:	US
Telephone Number	:	918-683-0753
Fax Number	:	866-397-7556

Provider Business Practice Location Address
First Line	:	350 S 40TH ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-4915
Country	:	US
Telephone Number	:	918-683-0753
Fax Number	:	866-397-7556

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	08/06/2015

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