Provider Demographics
NPI:1386689131
Name:DERUSSO, PATRICIA ANN (CRNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:DERUSSO
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9234
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILA - GASTRO & NUTRITION
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-3247
Practice Address - Fax:215-590-3606
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR114248208000000X
PAMD048053L2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD510050000Medicaid
MD510050000Medicaid
MDKR41991RMedicare ID - Type Unspecified