Provider Demographics
NPI:1467406884
Name:QUEEN, RUSSELL Q (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:Q
Last Name:QUEEN
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:550 STANTON CHRISTIANA RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2198
Mailing Address - Country:US
Mailing Address - Phone:302-633-9900
Mailing Address - Fax:302-633-9905
Practice Address - Street 1:550 STANTON CHRISTIANA RD
Practice Address - Street 2:SUITE 303
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2198
Practice Address - Country:US
Practice Address - Phone:303-633-9900
Practice Address - Fax:302-633-9905
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
DEC50000411363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEQ08682Medicare UPIN