Provider Demographics
NPI:1801300694
Name:RUSSO, SELENA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:ROSE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:ROSE
Other - Last Name:NIETO BALLESTERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:99-115 AIEA HEIGHTS DR STE 276B
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3924
Mailing Address - Country:US
Mailing Address - Phone:718-249-5360
Mailing Address - Fax:
Practice Address - Street 1:99-115 AIEA HEIGHTS DR STE 276B
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3924
Practice Address - Country:US
Practice Address - Phone:808-784-3050
Practice Address - Fax:808-486-5558
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-1004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant