Provider Demographics
NPI:1184609125
Name:ROUILLARD, RENALD (BS)
Entity type:Individual
Prefix:MR
First Name:RENALD
Middle Name:
Last Name:ROUILLARD
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SMITH RD
Mailing Address - Street 2:ATTN: PROFESSIONAL AFFAIRS
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02841-1002
Mailing Address - Country:US
Mailing Address - Phone:401-841-4522
Mailing Address - Fax:401-841-4128
Practice Address - Street 1:1 AYERS CIR
Practice Address - Street 2:BLDG H-1
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-3892
Practice Address - Country:US
Practice Address - Phone:207-438-1130
Practice Address - Fax:207-438-2438
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1005728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN