Provider Demographics
NPI:1669781720
Name:ROGERS, CHARLES CRAIG (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CRAIG
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8030 N LOOP DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-3226
Mailing Address - Country:US
Mailing Address - Phone:915-591-2704
Mailing Address - Fax:915-598-3946
Practice Address - Street 1:6974 GATEWAY BLVD E
Practice Address - Street 2:STE F
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1115
Practice Address - Country:US
Practice Address - Phone:915-774-8850
Practice Address - Fax:915-598-3946
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218708001Medicaid
TX218708001Medicaid