Provider Demographics
NPI:1275103467
Name:RUSSILLIO, JAMES HENRY (RN, BSN, CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:HENRY
Last Name:RUSSILLIO
Suffix:
Gender:M
Credentials:RN, BSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 SENECA CREEK RD APT RS
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2347
Mailing Address - Country:US
Mailing Address - Phone:716-946-7650
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-834-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY659979-01367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered