Provider Demographics
NPI:1871581520
Name:CUMMINS, ROGER R (PA-C)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:R
Last Name:CUMMINS
Suffix:
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 1:4509 S 6TH ST
Mailing Address - Street 2:STE 301
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4883
Mailing Address - Country:US
Mailing Address - Phone:541-883-8134
Mailing Address - Fax:541-883-1510
Practice Address - Street 1:2310 MOUNTAIN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1134
Practice Address - Country:US
Practice Address - Phone:541-883-8134
Practice Address - Fax:541-883-1510
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORQ52552Medicare UPIN
ORR0000WCHTWMedicare PIN
OR08WCHTWBMedicare PIN
ORR132625Medicare PIN