Provider Demographics
NPI:1609374503
Name:BROUSSEAU, RACHEL CAROLINE (PA)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:CAROLINE
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 PREUSSER RD
Mailing Address - Street 2:
Mailing Address - City:CRARYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12521-5259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2976 US-9W
Practice Address - Street 2:
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477
Practice Address - Country:US
Practice Address - Phone:518-264-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021754363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical