Provider Demographics
NPI:1760001820
Name:RODERICK, LINDSAY (ATC)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:RODERICK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MOUNT CARMEL AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-1961
Mailing Address - Country:US
Mailing Address - Phone:860-748-8415
Mailing Address - Fax:
Practice Address - Street 1:275 MOUNT CARMEL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-1961
Practice Address - Country:US
Practice Address - Phone:860-748-8415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant