Basic Information
| Provider Information | |||||||||
| NPI: | 1063783074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 HIGHLANDS DR | ||||||||
| Address2: | |||||||||
| City: | LITITZ | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175437694 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 HIGHLANDS DR | ||||||||
| Address2: | |||||||||
| City: | LITITZ | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175437694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179880000 | ||||||||
| FaxNumber: | 7177825716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2012 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106297 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA057357 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103476544 | 05 | PA | MEDICAID |