Provider Demographics
NPI:1124348404
Name:RUSSELL, RENO MORELLY (PA-C)
Entity type:Individual
Prefix:
First Name:RENO
Middle Name:MORELLY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:
Practice Address - Street 1:11550 COMMON OAKS DR STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8093
Practice Address - Country:US
Practice Address - Phone:919-453-5740
Practice Address - Fax:919-453-5741
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005764363A00000X
OH50.004332RX363A00000X
NC0010-11322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant