Provider Demographics
NPI:1790873099
Name:RUSSELL, STEVEN L (PA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 RUTLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5822
Mailing Address - Country:US
Mailing Address - Phone:843-723-1614
Mailing Address - Fax:843-727-2980
Practice Address - Street 1:191 RUTLEDGE AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5822
Practice Address - Country:US
Practice Address - Phone:843-723-1614
Practice Address - Fax:843-727-2980
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA281363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0264PAMedicaid
SC0264PAMedicaid