Provider Demographics
NPI:1699858258
Name:LARUSSA, RANDI RUTH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:RUTH
Last Name:LARUSSA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:100 ST CAMILLUS WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450
Mailing Address - Country:US
Mailing Address - Phone:585-377-4000
Mailing Address - Fax:585-377-0013
Practice Address - Street 1:435 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4629
Practice Address - Country:US
Practice Address - Phone:585-760-5466
Practice Address - Fax:585-760-5467
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY001164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB5548Medicare PIN