Provider Demographics
NPI:1649814997
Name:RUSSELL, HILARY LYNN (PA)
Entity type:Individual
Prefix:
First Name:HILARY
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 COUNTRY TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-2033
Mailing Address - Country:US
Mailing Address - Phone:727-432-1074
Mailing Address - Fax:
Practice Address - Street 1:280 EXECUTIVE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1838
Practice Address - Country:US
Practice Address - Phone:207-237-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13487363A00000X
FLPA9112671363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant