Basic Information
| Provider Information | |||||||||
| NPI: | 1336148147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | BENIDICT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7287 W RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW | ||||||||
| State: | PA | ||||||||
| PostalCode: | 164151130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148772360 | ||||||||
| FaxNumber: | 8144743561 | ||||||||
| Practice Location | |||||||||
| Address1: | 7287 W RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW | ||||||||
| State: | PA | ||||||||
| PostalCode: | 164151130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148772360 | ||||||||
| FaxNumber: | 8144743561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA000191L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00111403 | 01 | PA | RR MEDICARE | OTHER |