Provider Demographics
NPI:1619023322
Name:RUSSO, PAULA PETRULLO (PA)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:PETRULLO
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6568 FLOWING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH JUNCTION
Mailing Address - State:WV
Mailing Address - Zip Code:25442-4666
Mailing Address - Country:US
Mailing Address - Phone:304-876-3626
Mailing Address - Fax:
Practice Address - Street 1:207 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1613
Practice Address - Country:US
Practice Address - Phone:304-728-5051
Practice Address - Fax:304-728-9735
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical