Provider Demographics
NPI:1750855649
Name:RUSS, ANNALEE SANTOS (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ANNALEE
Middle Name:SANTOS
Last Name:RUSS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:ANNALEE
Other - Middle Name:THOMAS
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17820 SE 109TH AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8968
Mailing Address - Country:US
Mailing Address - Phone:352-693-2340
Mailing Address - Fax:352-693-2345
Practice Address - Street 1:17820 SE 109TH AVE STE 108
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8968
Practice Address - Country:US
Practice Address - Phone:352-693-2340
Practice Address - Fax:352-693-2345
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR200017915500OtherDRIVERS LICENSE