Provider Demographics
NPI:1295837334
Name:RUSSO, GINA F (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:F
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:F
Other - Last Name:GRUDINSKAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 PLEASANT ST STE 6073
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-7539
Mailing Address - Country:US
Mailing Address - Phone:603-227-7000
Mailing Address - Fax:603-227-7191
Practice Address - Street 1:250 PLEASANT ST STE 6073
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7539
Practice Address - Country:US
Practice Address - Phone:603-227-7000
Practice Address - Fax:603-227-7191
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0562363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH7817413092Medicare ID - Type Unspecified