Provider Demographics
NPI:1376782144
Name:PHILIP-ROUSSEAU, NIGEL MARTIN (PA)
Entity Type:Individual
Prefix:MR
First Name:NIGEL
Middle Name:MARTIN
Last Name:PHILIP-ROUSSEAU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1602
Mailing Address - Country:US
Mailing Address - Phone:973-450-1306
Mailing Address - Fax:973-450-1306
Practice Address - Street 1:3857 KINGS HWY
Practice Address - Street 2:SUITE 1L
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2943
Practice Address - Country:US
Practice Address - Phone:718-338-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant