Healthcare Provider Details

I. General information

NPI: 1235941444
Provider Name (Legal Business Name): CECILIA ROSE RUSSO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S WASHINGTON AVE STE 1000
SCRANTON PA
18505-3805
US

IV. Provider business mailing address

1620 MAIN ST
OLYPHANT PA
18447-1334
US

V. Phone/Fax

Practice location:
  • Phone: 570-941-0603
  • Fax:
Mailing address:
  • Phone: 570-336-3718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066309
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA007149
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: