Provider Demographics
NPI:1851990782
Name:RUSSO, DEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-5011
Mailing Address - Country:US
Mailing Address - Phone:212-686-7500
Mailing Address - Fax:
Practice Address - Street 1:423 E 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5011
Practice Address - Country:US
Practice Address - Phone:212-686-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant