Provider Demographics
NPI:1568784684
Name:RUSSO, DONNA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:A
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 1:5 E 98TH ST
Mailing Address - Street 2:BOX1188
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6501
Mailing Address - Country:US
Mailing Address - Phone:121-224-1810
Mailing Address - Fax:
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:BOX1188
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:121-224-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008624-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical