Provider Demographics
NPI:1558679381
Name:ROURKE, MEGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ROURKE
Suffix:
Gender:F
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 1:1245 NEW BRITAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-2404
Mailing Address - Country:US
Mailing Address - Phone:860-236-1303
Mailing Address - Fax:860-236-1317
Practice Address - Street 1:1245 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-2404
Practice Address - Country:US
Practice Address - Phone:860-236-1303
Practice Address - Fax:860-236-1317
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002412363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical