Individual
BETHANY RUSSOTTO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
3181 SW SAM JACKSON PARK RD # PPV05, PORTLAND, OR 97239-3098
(714) 449-7400
Mailing address
3181 SW SAM JACKSON PARK RD # PPV05, PORTLAND, OR 97239-3098
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA208945
OR
363A00000X
Physician Assistant
—
—
363AM0700X
Medical Physician Assistant
Primary
PA208945
OR
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
10/02/2019
Last updated
01/18/2022
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