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General NPI Number Information
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NPI Number | 1598543621
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Entity Type | Individual
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Provider Name | LILY MARIE RUSSELL PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/19/2023
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Last Update Date | 08/28/2024
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Provider Practice Location Address
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Address Line | 15 ENTERPRISE DR
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City | AUGUSTA
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State | ME
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Zip | 04330-7997
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Country | US
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Telephone | 207-621-8880
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Fax |
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Provider Business Mailing Address
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Address Line | 1109 TURNER ST
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City | AUBURN
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State | ME
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Zip | 04210-6426
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Country | US
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Telephone | 207-513-2896
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2691
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License Number State | ME
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