Provider Demographics
NPI:1831409135
Name:ROGERS, TARA NICOLE (PA)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:NICOLE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:800 FAIR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1720
Mailing Address - Country:US
Mailing Address - Phone:501-404-8007
Mailing Address - Fax:501-904-3620
Practice Address - Street 1:505 E DAVE WARD DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7825
Practice Address - Country:US
Practice Address - Phone:501-500-3500
Practice Address - Fax:501-904-3620
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363AS0400X
ARPA-513363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPA513OtherLICENSE