Provider Demographics
NPI:1659420891
Name:ROUSSEAU, THOMAS G (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:ROUSSEAU
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 1:1 ELLIOT WAY
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3502
Mailing Address - Country:US
Mailing Address - Phone:603-663-2850
Mailing Address - Fax:603-663-1849
Practice Address - Street 1:1 ELLIOT WAY
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3502
Practice Address - Country:US
Practice Address - Phone:603-663-2850
Practice Address - Fax:603-663-1849
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH426P363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30331918Medicaid
NH30331918Medicaid
NHP53745Medicare UPIN