Provider Demographics
NPI:1548938863
Name:ROGERS, WALKER MITCHELL
Entity type:Individual
Prefix:
First Name:WALKER
Middle Name:MITCHELL
Last Name:ROGERS
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 1:2104 NORTHDALE BLVD NW STE 220
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3046
Mailing Address - Country:US
Mailing Address - Phone:763-537-6000
Mailing Address - Fax:763-537-6666
Practice Address - Street 1:2104 NORTHDALE BLVD NW STE 220
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3046
Practice Address - Country:US
Practice Address - Phone:763-537-6000
Practice Address - Fax:763-537-6666
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14760363A00000X, 363A00000X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program