MEDICARE: SARAH ROUSAKIS PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10002819A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10002819A	OTHER	IN	INDIANA LICENSE

General Provider Information

NPI Number	:	1225670367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH ROUSAKIS PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	151 SOUTHHALL LN STE 300
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7172
Country	:	US
Telephone Number	:	517-886-0333
Fax Number	:	517-886-2072

Provider Business Practice Location Address
First Line	:	416 S CREYTS RD STE A
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917-8290
Country	:	US
Telephone Number	:	517-886-0333
Fax Number	:	517-886-2072

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2019
Last Update Date	:	01/13/2026

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