Healthcare Provider Details

I. General information

NPI: 1336148147
Provider Name (Legal Business Name): LAWRENCE BENIDICT RUSSELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7287 W RIDGE RD
FAIRVIEW PA
16415-1130
US

IV. Provider business mailing address

7287 W RIDGE RD
FAIRVIEW PA
16415-1130
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-2360
  • Fax: 814-474-3561
Mailing address:
  • Phone: 814-877-2360
  • Fax: 814-474-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA000191L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: