Provider Demographics
NPI:1144254616
Name:MENDENHALL, ROGER GEORGE (CRNA)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:GEORGE
Last Name:MENDENHALL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 LINDA DR
Mailing Address - Street 2:PO BOX 601
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-2728
Mailing Address - Country:US
Mailing Address - Phone:712-243-4563
Mailing Address - Fax:712-243-4563
Practice Address - Street 1:805 LINDA DR
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-2728
Practice Address - Country:US
Practice Address - Phone:712-243-4563
Practice Address - Fax:712-243-4563
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD047194367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0061069Medicaid
IA26648Medicare ID - Type UnspecifiedPROVIDER NUMBER