Provider Demographics
NPI:1144296872
Name:MASTERS, ROGER DAVID (CRNA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DAVID
Last Name:MASTERS
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:PO BOX 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:478-714-7812
Mailing Address - Fax:
Practice Address - Street 1:80 NEWNAN STATION DR
Practice Address - Street 2:SUITE A
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5209
Practice Address - Country:US
Practice Address - Phone:770-251-2060
Practice Address - Fax:678-854-9235
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN062574367500000X
NMCRNA01013367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00547137CMedicaid
GA430076996OtherMCRB RR
GA00547137CMedicaid