MEDICARE: MRS. CAROL D RUSSELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA2709	FL
2	363AM0700X	Medical Physician Assistant	PA2709	FL
3	363AM0700X	Medical Physician Assistant	LL861	FL

General Provider Information

NPI Number	:	1336134865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL D RUSSELL PA-C

Provider Business Mailing Address
First Line	:	2555 JUDGE FRAN JAMIESON WAY
Second Line	:
City	:	VIERA
State	:	FL
Zip	:	32940-5998
Country	:	US
Telephone Number	:	321-639-5813
Fax Number	:	321-637-7312

Provider Business Practice Location Address
First Line	:	SPACE COAST VOLUNTEERS IN MEDICINE
Second Line	:	2555 JUDGE FRAN JAMIESON WAY
City	:	VIERA
State	:	FL
Zip	:	32940
Country	:	US
Telephone Number	:	321-639-5813
Fax Number	:	321-637-7312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	01/26/2024

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