Provider Demographics
NPI:1760140529
Name:RUSSIN, SAMANTHA JO (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JO
Last Name:RUSSIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:59 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:GLEN LYON
Mailing Address - State:PA
Mailing Address - Zip Code:18617-1005
Mailing Address - Country:US
Mailing Address - Phone:570-266-1473
Mailing Address - Fax:
Practice Address - Street 1:1000 ALLIANCE DR
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-3234
Practice Address - Country:US
Practice Address - Phone:570-501-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063121363A00000X
PAOA005919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant