Provider Demographics
NPI:1881210946
Name:RUSSELL, ANDREW MARTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARTIN
Last Name:RUSSELL
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 1:200 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:THORNDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19372-1058
Mailing Address - Country:US
Mailing Address - Phone:610-383-6300
Mailing Address - Fax:610-383-0114
Practice Address - Street 1:200 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:THORNDALE
Practice Address - State:PA
Practice Address - Zip Code:19372-1058
Practice Address - Country:US
Practice Address - Phone:610-383-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine