Provider Demographics
NPI:1689614356
Name:RUSSELL, SUSAN P (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:RUSSELL
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 1:1450 BOBLETTS GAP RD
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:VA
Mailing Address - Zip Code:24066-5334
Mailing Address - Country:US
Mailing Address - Phone:540-798-1970
Mailing Address - Fax:
Practice Address - Street 1:213 MCCLANAHAN ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1721
Practice Address - Country:US
Practice Address - Phone:540-981-8025
Practice Address - Fax:540-982-3404
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24166830363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010266572Medicaid
010138C41Medicare PIN
VAQ69305Medicare UPIN