Provider Demographics
NPI:1316245236
Name:BAZDARIC-RUSSELL, MARA A (FNP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:A
Last Name:BAZDARIC-RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 HAMMOND LANE
Mailing Address - Street 2:STE 2
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-563-5900
Mailing Address - Fax:
Practice Address - Street 1:348 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:MOIRA
Practice Address - State:NY
Practice Address - Zip Code:12957
Practice Address - Country:US
Practice Address - Phone:518-521-7218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336641363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily