Healthcare Provider Details

I. General information

NPI: 1992497903
Provider Name (Legal Business Name): TIMOTHY ARTHUR ROUSSEAU PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9521 SAN MATEO BLVD NE
ALBUQUERQUE NM
87113-2237
US

IV. Provider business mailing address

4472 BATTLEVIEW PL
SMYRNA GA
30082-4480
US

V. Phone/Fax

Practice location:
  • Phone: 505-923-5941
  • Fax:
Mailing address:
  • Phone: 770-375-0998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: