Provider Demographics
NPI:1316436504
Name:ROGERS, RAEGAN (NP)
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-5235
Mailing Address - Country:US
Mailing Address - Phone:205-349-3250
Mailing Address - Fax:205-752-1517
Practice Address - Street 1:631 BESSEMER SUPER HWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35228
Practice Address - Country:US
Practice Address - Phone:205-241-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF10170336363LF0000X
AL1-132052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty