Provider Demographics
NPI:1518414721
Name:RODGERS, DESEAN
Entity type:Individual
Prefix:
First Name:DESEAN
Middle Name:
Last Name:RODGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14587 NE 35TH ST
Mailing Address - Street 2:I-311
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-8550
Mailing Address - Country:US
Mailing Address - Phone:719-930-9993
Mailing Address - Fax:
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:BOX # 359732
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-744-9240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60683616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant