Provider Demographics
NPI:1013907229
Name:HORN, RUSSELL A (PA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
Last Name:HORN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:208 LIFELINE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-6473
Mailing Address - Country:US
Mailing Address - Phone:570-664-8770
Mailing Address - Fax:570-664-8771
Practice Address - Street 1:3361 ROUTE 611 STE 2
Practice Address - Street 2:
Practice Address - City:BARTONSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18321-7821
Practice Address - Country:US
Practice Address - Phone:272-639-5320
Practice Address - Fax:866-230-6712
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000101L363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S00288Medicare UPIN
083686FKHMedicare ID - Type Unspecified