Provider Demographics
NPI:1568460608
Name:ROUSSELOT, ANTHONY MAX (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MAX
Last Name:ROUSSELOT
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 1:1600 WEEOT WAY
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4734
Mailing Address - Country:US
Mailing Address - Phone:707-825-5010
Mailing Address - Fax:707-825-6736
Practice Address - Street 1:1600 WEEOT WAY
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4734
Practice Address - Country:US
Practice Address - Phone:707-825-5010
Practice Address - Fax:707-825-6736
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13540363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEN021ZOtherMEDICARE PART B - PTAN
CA0PA135400Medicare ID - Type Unspecified
CAEN021ZOtherMEDICARE PART B - PTAN