Healthcare Provider Details

I. General information

NPI: 1699701540
Provider Name (Legal Business Name): EMILY A RUSSELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 AMHERST ST
WINCHESTER VA
22601-2801
US

IV. Provider business mailing address

148 LINDEN DR SUITE 101
WINCHESTER VA
22601-6902
US

V. Phone/Fax

Practice location:
  • Phone: 540-667-8724
  • Fax: 540-723-0741
Mailing address:
  • Phone: 540-504-0075
  • Fax: 540-678-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001174
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: