Provider Demographics
NPI:1790769032
Name:ROUSSEAU, CHRISTY A (MS PA C)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:A
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:MS PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MILES ST
Mailing Address - Street 2:MILES MEDICAL GROUP EMERGENCY DEPT
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4047
Mailing Address - Country:US
Mailing Address - Phone:207-563-4521
Mailing Address - Fax:207-563-3717
Practice Address - Street 1:35 MILES ST
Practice Address - Street 2:MILES MEDICAL GROUP EMERGENCY DEPT
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:207-563-4521
Practice Address - Fax:207-563-3717
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAP1173Medicare ID - Type Unspecified
S97422Medicare UPIN