Provider Demographics
NPI:1275546277
Name:THEROUX, BRIAN R (PA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:R
Last Name:THEROUX
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1672 S COUNTY TRL
Mailing Address - Street 2:STE. 301
Mailing Address - City:E GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-5098
Mailing Address - Country:US
Mailing Address - Phone:401-885-7546
Mailing Address - Fax:401-885-5465
Practice Address - Street 1:1672 S COUNTY TRL
Practice Address - Street 2:STE 101
Practice Address - City:E GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-5098
Practice Address - Country:US
Practice Address - Phone:401-885-7546
Practice Address - Fax:401-885-6658
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-06-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
RIPA00289363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDE76182Medicaid
RIDE76182Medicaid
RI0011435Medicare PIN
RI3890033341Medicare PIN