Provider Demographics
NPI:1790744381
Name:KROUSON, IAN PAUL (PA)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:PAUL
Last Name:KROUSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 S BAY DR
Mailing Address - Street 2:UNIT A2
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-2870
Mailing Address - Country:US
Mailing Address - Phone:860-460-7361
Mailing Address - Fax:
Practice Address - Street 1:1195 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1824
Practice Address - Country:US
Practice Address - Phone:401-861-3782
Practice Address - Fax:401-383-5846
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00398363AM0700X
CT001472363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPA00398OtherRI LICENSE PA#