Provider Demographics
NPI:1851775407
Name:RUSSELL, KIMBERLY MURO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MURO
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:MURO RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:907 MCKEAN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2326
Mailing Address - Country:US
Mailing Address - Phone:267-247-6013
Mailing Address - Fax:215-707-9131
Practice Address - Street 1:3509 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4105
Practice Address - Country:US
Practice Address - Phone:215-707-8484
Practice Address - Fax:215-707-3946
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant