Provider Demographics
NPI:1275976052
Name:ROSSIGNOL, JOHN CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:ROSSIGNOL
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 1:36 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3801
Mailing Address - Country:US
Mailing Address - Phone:860-677-5533
Mailing Address - Fax:860-678-1305
Practice Address - Street 1:36 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3801
Practice Address - Country:US
Practice Address - Phone:860-677-5533
Practice Address - Fax:860-678-1305
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES75045Medicare UPIN