Individual
KYLE A RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
6 WEST AIRPORT ROAD, LITITZ, PA 17543
(717) 627-2108
Mailing address
6 W NEWPORT RD, LITITZ, PA 17543-7774
(717) 627-2108
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
OA002311
PA
363AM0700X
Medical Physician Assistant
Primary
MA053822
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00667984
MEDICARE RAILROAD
PA
Enumeration date
11/20/2008
Last updated
11/29/2012
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