Healthcare Provider Details

I. General information

NPI: 1013907229
Provider Name (Legal Business Name): RUSSELL A HORN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3361 ROUTE 611 STE 2
BARTONSVILLE PA
18321-7821
US

IV. Provider business mailing address

208 LIFELINE RD SUITE 203
STROUDSBURG PA
18360-6473
US

V. Phone/Fax

Practice location:
  • Phone: 272-639-5320
  • Fax: 866-230-6712
Mailing address:
  • Phone: 570-664-8770
  • Fax: 570-664-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA000101L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA000101L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: