Provider Demographics
NPI:1902804412
Name:RUSSO, THOMAS ANTHONY (PA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ANTHONY
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 LAW ST
Mailing Address - Street 2:
Mailing Address - City:COXSACKIE
Mailing Address - State:NY
Mailing Address - Zip Code:12192
Mailing Address - Country:US
Mailing Address - Phone:518-731-2120
Mailing Address - Fax:518-731-2070
Practice Address - Street 1:9 LAW ST
Practice Address - Street 2:
Practice Address - City:COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192
Practice Address - Country:US
Practice Address - Phone:518-731-2120
Practice Address - Fax:518-731-2070
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004434-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYOF6941Medicare ID - Type Unspecified
P06055Medicare UPIN