Individual
GARRETT MICHAEL RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1001 E 2ND ST, COUDERSPORT, PA 16915-8161
(814) 274-7474
Mailing address
1001 E 2ND ST, COUDERSPORT, PA 16915-8161
(814) 274-7474
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
MA060807
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MA060807
LICENSE NUMBER
PA
Enumeration date
05/09/2019
Last updated
04/02/2021
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