Provider Demographics
NPI:1023193133
Name:RUSS, MARIA (ARNP, CPNP, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:ARNP, CPNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17709 GREY EAGLE RD
Mailing Address - Street 2:SAME
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2261
Mailing Address - Country:US
Mailing Address - Phone:813-994-7736
Mailing Address - Fax:
Practice Address - Street 1:17709 GREY EAGLE RD
Practice Address - Street 2:SAME
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2261
Practice Address - Country:US
Practice Address - Phone:813-994-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2562902363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics