Provider Demographics
NPI:1902078587
Name:BARNES, ROGER DALE (DNP)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:BARNES
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2946 WINFIELD DUNN PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:KODAK
Mailing Address - State:TN
Mailing Address - Zip Code:37764-4316
Mailing Address - Country:US
Mailing Address - Phone:865-933-9950
Mailing Address - Fax:
Practice Address - Street 1:2946 WINFIELD DUNN PARKWAY
Practice Address - Street 2:SUITE 107
Practice Address - City:KODAK
Practice Address - State:TN
Practice Address - Zip Code:37764
Practice Address - Country:US
Practice Address - Phone:865-933-9950
Practice Address - Fax:865-465-3937
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN163W00000X
TNAPN0000013355363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1526565Medicaid
TN1526565Medicaid