Provider Demographics
NPI:1760260772
Name:RUSSO, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 CHILLMARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-6472
Mailing Address - Country:US
Mailing Address - Phone:919-619-2623
Mailing Address - Fax:
Practice Address - Street 1:433 MCALISTER RD
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4147
Practice Address - Country:US
Practice Address - Phone:980-212-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant