Provider Demographics
NPI:1336134865
Name:RUSSELL, CAROL D (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:D
Last Name:RUSSELL
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 1:2555 JUDGE FRAN JAMIESON WAY
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-5998
Mailing Address - Country:US
Mailing Address - Phone:321-639-5813
Mailing Address - Fax:321-637-7312
Practice Address - Street 1:SPACE COAST VOLUNTEERS IN MEDICINE
Practice Address - Street 2:2555 JUDGE FRAN JAMIESON WAY
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-639-5813
Practice Address - Fax:321-637-7312
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2709363A00000X, 363AM0700X
FLLL861363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6284ZMedicare ID - Type Unspecified
Q55424Medicare UPIN