Individual
NICOLE RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
100 PORT WASHINGTON BLVD, ROSLYN, NY 11576-1347
(516) 562-6006
Mailing address
10 LACE LN, WESTBURY, NY 11590-6315
(516) 319-7326
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
—
—
Other
Enumeration date
06/15/2023
Last updated
06/15/2023
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