Individual
KASSIE RUSSOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
316 CALHOUN ST, CHARLESTON, SC 29401-1113
(843) 724-2450
Mailing address
PO BOX 751649, CHARLOTTE, NC 28275-1649
(843) 789-1620
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
3982
SC
363A00000X
Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5029PA
—
SC
Enumeration date
01/20/2021
Last updated
07/11/2022
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