Provider Demographics
NPI:1457405144
Name:RUSS, SHANNAN R (NP)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:R
Last Name:RUSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:R
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:722 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2435
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2099
Practice Address - Street 1:600 IVY ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1627
Practice Address - Country:US
Practice Address - Phone:607-737-7780
Practice Address - Fax:607-737-7788
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02001921Medicaid
NY02001921Medicaid