Provider Demographics
NPI:1326004375
Name:RUSSO, CYNTHIA A (CRNA)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:571-777-5102
Mailing Address - Fax:703-563-6256
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18764-0001
Practice Address - Country:US
Practice Address - Phone:814-877-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN291004L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA015331Medicare PIN
S62413Medicare UPIN