Provider Demographics
NPI:1356322358
Name:ROESSLER, ELIZABETH MAE (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAE
Last Name:ROESSLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 208237
Mailing Address - Street 2:55 LOCK ST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:05511
Mailing Address - Country:US
Mailing Address - Phone:203-432-0076
Mailing Address - Fax:203-432-7289
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3733
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-401-2042
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT290000673CT03OtherANTHEM BCBS
CT970025160OtherRAILROAD MEDICARE
CTP2685637OtherOXFORD
CT0V8014OtherHEALTHNET
CT673000I420OtherCONNECTICARE
CTP2685637OtherOXFORD
CT290000673CT03OtherANTHEM BCBS