Basic Information
| Provider Information | |||||||||
| NPI: | 1063411734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308 FAIRWAY TER | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881013037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
| FaxNumber: | 5736862139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 N DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881019412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
| FaxNumber: | 5736862139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R45276 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | NM006777 | 01 | NM | INDIVIDUAL BCBS | OTHER | B0539 | 05 | NM | MEDICAID |