Provider Demographics
NPI:1457436966
Name:RUSS, EMILY L (PA)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:L
Last Name:RUSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 E LONGVIEW DR STE B
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2164
Mailing Address - Country:US
Mailing Address - Phone:920-475-0333
Mailing Address - Fax:
Practice Address - Street 1:626 E LONGVIEW DR STE B
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-2164
Practice Address - Country:US
Practice Address - Phone:920-475-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4355-23363A00000X
MT417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000009901OtherFACILITY PROVIDER NUMBER
MTQ45080Medicare UPIN
MT000071809Medicare PIN