Provider Demographics
NPI:1336148147
Name:RUSSELL, LAWRENCE BENIDICT (PA-C)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:BENIDICT
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 1:7287 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-1130
Mailing Address - Country:US
Mailing Address - Phone:814-877-2360
Mailing Address - Fax:814-474-3561
Practice Address - Street 1:7287 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-1130
Practice Address - Country:US
Practice Address - Phone:814-877-2360
Practice Address - Fax:814-474-3561
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000191L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00111403OtherRR MEDICARE
PAP00111403OtherRR MEDICARE
S14124Medicare UPIN