Individual
LAWRENCE BENIDICT RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
7287 W RIDGE RD, FAIRVIEW, PA 16415-1130
(814) 877-2360
(814) 474-3561
Mailing address
7287 W RIDGE RD, FAIRVIEW, PA 16415-1130
(814) 877-2360
(814) 474-3561
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
MA000191L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00111403
RR MEDICARE
PA
Enumeration date
07/14/2005
Last updated
04/16/2013
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