Provider Demographics
NPI:1700408317
Name:RUSSELL, ANN CATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:CATHERINE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:BOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-858-8353
Mailing Address - Fax:207-474-9261
Practice Address - Street 1:46 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1481
Practice Address - Country:US
Practice Address - Phone:207-474-5121
Practice Address - Fax:207-474-3441
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
METPA378363A00000X
MEPA378363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant