Provider Demographics
NPI:1699861625
Name:ROGERS, PATRICIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2810
Mailing Address - Country:US
Mailing Address - Phone:386-236-3200
Mailing Address - Fax:
Practice Address - Street 1:1220 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2810
Practice Address - Country:US
Practice Address - Phone:386-236-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00066900363LP0808X, 363LF0000X
FL9415718363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6070190Medicaid
NJ107255Medicare PIN
NJ6070190Medicaid
NJ086351DNUMedicare Oscar/Certification