Provider Demographics
NPI:1508449026
Name:RUSSO, VICTORIA (PA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:COGNATA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 8519
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-8519
Mailing Address - Country:US
Mailing Address - Phone:732-460-9840
Mailing Address - Fax:732-460-9848
Practice Address - Street 1:363 STATE ROUTE 36
Practice Address - Street 2:
Practice Address - City:PORT MONMOUTH
Practice Address - State:NJ
Practice Address - Zip Code:07758-1359
Practice Address - Country:US
Practice Address - Phone:732-471-0400
Practice Address - Fax:732-471-7949
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant