Provider Demographics
NPI:1013545607
Name:RUSSO, RAQUEL K (PA)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:K
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:17300 N OUTER 40 RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1364
Mailing Address - Country:US
Mailing Address - Phone:636-778-2900
Mailing Address - Fax:636-778-2828
Practice Address - Street 1:17300 N OUTER 40 RD STE 201
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1364
Practice Address - Country:US
Practice Address - Phone:636-778-2900
Practice Address - Fax:636-778-2828
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2022-10-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2022005794363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant