Healthcare Provider Details

I. General information

NPI: 1255266136
Provider Name (Legal Business Name): MIRANDA KATHERINE RUSSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 LANARK RD STE 201
CENTER VALLEY PA
18034-8694
US

IV. Provider business mailing address

5445 LANARK RD STE 201
CENTER VALLEY PA
18034-8694
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-5270
  • Fax:
Mailing address:
  • Phone: 484-526-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: