Healthcare Provider Details

I. General information

NPI: 1760140529
Provider Name (Legal Business Name): SAMANTHA JO RUSSIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ALLIANCE DR
HAZLE TOWNSHIP PA
18202-3234
US

IV. Provider business mailing address

59 RAILROAD ST
GLEN LYON PA
18617-1005
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6450
  • Fax:
Mailing address:
  • Phone: 570-266-1473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA063121
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA005919
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: