Provider Demographics
NPI:1316954357
Name:CLARK ROGERS, PATRICIA LEE (PT)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:LEE
Last Name:CLARK ROGERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5905
Mailing Address - Country:US
Mailing Address - Phone:402-462-8824
Mailing Address - Fax:402-462-8017
Practice Address - Street 1:207 S BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5905
Practice Address - Country:US
Practice Address - Phone:402-462-8824
Practice Address - Fax:402-462-8017
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE8792OtherBLUE CROSS BLUE SHIELD
NE260220Medicare PIN