Basic Information
| Provider Information | |||||||||
| NPI: | 1932532462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | MSC 8515-87-1200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546018 | ||||||||
| FaxNumber: | 8446214392 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | DIV PED HEMATOLOGY & ONC | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546018 | ||||||||
| FaxNumber: | 8446214392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2013 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 2019005207 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2100X | 2019005207 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 420076824 | 05 | MO | MEDICAID |