Provider Demographics
NPI:1063688265
Name:ROUSTER, AUDRA SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:SUZANNE
Last Name:ROUSTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:PO BOX 9214
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9214
Mailing Address - Country:US
Mailing Address - Phone:304-293-1017
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:9214
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-9214
Practice Address - Country:US
Practice Address - Phone:304-293-1017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV259702080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology