Individual
COREY CRAIG BOUSQUET
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1918 BLACK ROCK TPKE, FAIRFIELD, CT 06825-3543
(203) 583-8400
Mailing address
45 MALER AVE, SHELTON, CT 06484-5925
(305) 528-9800
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2478
CT
363A00000X
Physician Assistant
PA9102466
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
291035
AMERIGROUP
FL
05
—
292171500
—
FL
Enumeration date
05/17/2006
Last updated
01/25/2024
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