Provider Demographics
NPI:1154054955
Name:RUSSILLO, GABRIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:RUSSILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 PEASLEY DR
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-1766
Mailing Address - Country:US
Mailing Address - Phone:908-328-6341
Mailing Address - Fax:
Practice Address - Street 1:579A CRANBURY RD STE 202
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5426
Practice Address - Country:US
Practice Address - Phone:732-254-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00713400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant