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NPI Code Detail

MEDICARE: ANTHONY MAX ROUSSELOT PA-C

MEDICARE: ANTHONY MAX ROUSSELOT PA-C
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
1363AM0700XMedical Physician AssistantPA13540CA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1EN021ZOTHERCAMEDICARE PART B - PTAN

General Provider Information

NPI Number : 1568460608
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANTHONY MAX ROUSSELOT PA-C
Provider Business Mailing Address
First Line : 1600 WEEOT WAY
Second Line :
City : ARCATA
State : CA
Zip : 95521-4734
Country : US
Telephone Number : 707-825-5010
Fax Number : 707-825-6736
Provider Business Practice Location Address
First Line : 1600 WEEOT WAY
Second Line :
City : ARCATA
State : CA
Zip : 95521-4734
Country : US
Telephone Number : 707-825-5010
Fax Number : 707-825-6736
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/12/2005
Last Update Date : 09/14/2022

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Directions to “ ANTHONY MAX ROUSSELOT PA-C” Practice Location

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