Provider Demographics
NPI:1104150788
Name:RUSSELL, DEIRDRE A (PA-C)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6224
Mailing Address - Country:US
Mailing Address - Phone:610-435-1003
Mailing Address - Fax:610-435-3184
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-435-1003
Practice Address - Fax:610-435-3184
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATMA052143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant