Provider Demographics
NPI:1164211041
Name:NOTTINGHAM, ROGER L JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:L
Last Name:NOTTINGHAM
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 VISTA PORTOLA LOOP
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-0258
Mailing Address - Country:US
Mailing Address - Phone:949-257-3043
Mailing Address - Fax:
Practice Address - Street 1:344 VISTA PORTOLA LOOP
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642-0258
Practice Address - Country:US
Practice Address - Phone:949-257-3043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant