Provider Demographics
NPI:1063402006
Name:CORDIAL, ROGER (PAC)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:CORDIAL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 S HORNER BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4822
Mailing Address - Country:US
Mailing Address - Phone:919-776-6767
Mailing Address - Fax:919-776-6773
Practice Address - Street 1:724 S HORNER BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4822
Practice Address - Country:US
Practice Address - Phone:919-776-6767
Practice Address - Fax:919-776-6773
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102837363AM0700X
NC102171363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34771OtherGROUP MEDICARE
NC2752787Medicare ID - Type Unspecified
FL34771OtherGROUP MEDICARE