Provider Demographics
NPI:1659405835
Name:RUSSAK, LISA (NP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:RUSSAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 BEACH 141ST ST
Mailing Address - Street 2:
Mailing Address - City:BELLE HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1229
Mailing Address - Country:US
Mailing Address - Phone:917-848-2463
Mailing Address - Fax:
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:718-250-6534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303001363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health