Provider Demographics
NPI:1710539416
Name:RUSSELL, JUSTIN LEE (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:11505 RANGELAND PKWY
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-4041
Mailing Address - Country:US
Mailing Address - Phone:941-362-8662
Mailing Address - Fax:941-362-8602
Practice Address - Street 1:11505 RANGELAND PKWY
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-4041
Practice Address - Country:US
Practice Address - Phone:941-362-8662
Practice Address - Fax:941-362-8602
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2020-05-07
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical