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 1:11521 N FM 620 RD STE 945
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-1115
Practice Address - Country:US
Practice Address - Phone:512-318-2559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA19342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant