Healthcare Provider Details

I. General information

NPI: 1659420891
Provider Name (Legal Business Name): THOMAS G ROUSSEAU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 RIVERWAY PL
BEDFORD NH
03110-6745
US

IV. Provider business mailing address

703 RIVERWAY PL
BEDFORD NH
03110-6745
US

V. Phone/Fax

Practice location:
  • Phone: 603-627-1661
  • Fax: 603-669-6944
Mailing address:
  • Phone: 603-627-1661
  • Fax: 603-669-6944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number426P
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number426P
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: