Healthcare Provider Details

I. General information

NPI: 1982122180
Provider Name (Legal Business Name): PAOLA RUSSO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8905 SW 87TH AVE STE 100
MIAMI FL
33176-2210
US

IV. Provider business mailing address

8905 SW 87TH AVE STE 100
MIAMI FL
33176-2210
US

V. Phone/Fax

Practice location:
  • Phone: 305-667-8686
  • Fax: 305-667-8680
Mailing address:
  • Phone: 305-667-8686
  • Fax: 305-667-8680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: