Provider Demographics
NPI:1356431456
Name:RUSSO, PETER JOHN (PA-C)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
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 1:211 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MOGADORE
Mailing Address - State:OH
Mailing Address - Zip Code:44260-2022
Mailing Address - Country:US
Mailing Address - Phone:330-628-5508
Mailing Address - Fax:
Practice Address - Street 1:55 W WATERLOO RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-1116
Practice Address - Country:US
Practice Address - Phone:330-724-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.000448363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical