Provider Demographics
NPI:1801040613
Name:ROOT, ELYSSA L (PA)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:L
Last Name:ROOT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELYSSA
Other - Middle Name:L
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 CROMWELL AVE STE 403
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3454
Mailing Address - Country:US
Mailing Address - Phone:860-525-4469
Mailing Address - Fax:860-999-9305
Practice Address - Street 1:1111 CROMWELL AVE STE 404
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067
Practice Address - Country:US
Practice Address - Phone:860-525-4469
Practice Address - Fax:860-278-8032
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23-012973363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA0265Medicare PIN
A400005910Medicare PIN
J400000642Medicare PIN
W9FF11Medicare PIN