Provider Demographics
NPI:1346516408
Name:RUSSO, ALYSE CORTNEY (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:ALYSE
Middle Name:CORTNEY
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RAINBOW TRL
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-3208
Mailing Address - Country:US
Mailing Address - Phone:973-462-9455
Mailing Address - Fax:
Practice Address - Street 1:870 PALISADE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3419
Practice Address - Country:US
Practice Address - Phone:201-836-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00279700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant