Provider Demographics
NPI:1164823787
Name:RUSSO, SAM DOMINICK (MPAS)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:DOMINICK
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MPAS
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Mailing Address - Street 1:3632 WILDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-1129
Mailing Address - Country:US
Mailing Address - Phone:914-582-8342
Mailing Address - Fax:914-245-1394
Practice Address - Street 1:650 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3702
Practice Address - Country:US
Practice Address - Phone:212-305-7367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical