Provider Demographics
NPI:1356719652
Name:RUSSO, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 TURKEY RD
Mailing Address - Street 2:
Mailing Address - City:KEMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:19529-8734
Mailing Address - Country:US
Mailing Address - Phone:908-304-5738
Mailing Address - Fax:
Practice Address - Street 1:1 W BROAD ST
Practice Address - Street 2:SUITE 506
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-5717
Practice Address - Country:US
Practice Address - Phone:610-954-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN619623367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered