Provider Demographics
NPI:1780745554
Name:RUSSIN, KELLY (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RUSSIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6325 SHANNON PKWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-1538
Mailing Address - Country:US
Mailing Address - Phone:770-964-1400
Mailing Address - Fax:770-306-1343
Practice Address - Street 1:6325 SHANNON PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-1538
Practice Address - Country:US
Practice Address - Phone:770-964-1400
Practice Address - Fax:770-306-1343
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA004096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P99038Medicare UPIN
97WCFBWMedicare ID - Type Unspecified