Provider Demographics
NPI:1700161312
Name:RUSSO, DANIELLE MARIE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:DANIELLE
Middle Name:MARIE
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 1:550 OSBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1899
Mailing Address - Country:US
Mailing Address - Phone:906-635-4460
Mailing Address - Fax:
Practice Address - Street 1:558 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-4001
Practice Address - Country:US
Practice Address - Phone:906-635-9090
Practice Address - Fax:906-635-9091
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant