Provider Demographics
NPI:1659879310
Name:ROUSH, MICHELLE BEASON (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BEASON
Last Name:ROUSH
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 1:24600 W 127TH ST STE 340
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9507
Mailing Address - Country:US
Mailing Address - Phone:815-731-9110
Mailing Address - Fax:815-731-9110
Practice Address - Street 1:24600 W 127TH ST STE 340
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-9507
Practice Address - Country:US
Practice Address - Phone:815-731-9110
Practice Address - Fax:815-731-9110
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant