Provider Demographics
NPI:1841185014
Name:ROUSSEAU, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 BROOKSIDE AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1304
Mailing Address - Country:US
Mailing Address - Phone:929-351-9548
Mailing Address - Fax:
Practice Address - Street 1:194 BROOKSIDE AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10553-1304
Practice Address - Country:US
Practice Address - Phone:929-351-9548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311471363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health