Provider Demographics
NPI:1629753975
Name:RUSSELL, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RUSSELL
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 1:10 LACE LN
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6315
Mailing Address - Country:US
Mailing Address - Phone:516-319-7326
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1347
Practice Address - Country:US
Practice Address - Phone:516-562-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical