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NPI Code Detail

MEDICARE: MR. DANIEL RUSSELL

MEDICARE: MR. DANIEL RUSSELL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1760056238
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. DANIEL RUSSELL
Provider Business Mailing Address
First Line : 225 CARMITA AVE
Second Line :
City : RUTHERFORD
State : NJ
Zip : 07070-1654
Country : US
Telephone Number : 201-414-3004
Fax Number :
Provider Business Practice Location Address
First Line : 78 BEAVER ST
Second Line :
City : BROOKLYN
State : NY
Zip : 11206-4504
Country : US
Telephone Number : 718-406-6037
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/18/2021
Last Update Date : 05/31/2021

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