Provider Demographics
NPI:1518616341
Name:RUSSO, JOSEPHINE MARY (PA-C)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:MARY
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:947 S MANNHEIM RD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-2515
Mailing Address - Country:US
Mailing Address - Phone:920-883-7509
Mailing Address - Fax:
Practice Address - Street 1:947 S MANNHEIM RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2515
Practice Address - Country:US
Practice Address - Phone:708-550-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty