Provider Demographics
NPI:1346837564
Name:RUSSO, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RUSSO
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 1:9847 MONTAGUE ST
Mailing Address - Street 2:
Mailing Address - City:WESTCHASE
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1863
Mailing Address - Country:US
Mailing Address - Phone:239-595-4229
Mailing Address - Fax:
Practice Address - Street 1:1607 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-4203
Practice Address - Country:US
Practice Address - Phone:727-329-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL91137102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty