Provider Demographics
NPI:1942429584
Name:RUSSELL, CONCETTA M (PA)
Entity Type:Individual
Prefix:
First Name:CONCETTA
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 NICHOLAS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:MA
Mailing Address - Zip Code:01523
Mailing Address - Country:US
Mailing Address - Phone:978-706-1522
Mailing Address - Fax:
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:SUITE 590
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-852-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000062-1363A00000X
MA2518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant