Provider Demographics
NPI:1407697683
Name:RIDULFO, RUSSELL JOHN (PA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JOHN
Last Name:RIDULFO
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12 MAPLE GLEN LN
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1712
Mailing Address - Country:US
Mailing Address - Phone:631-942-0295
Mailing Address - Fax:
Practice Address - Street 1:12 MAPLE GLEN LN
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1712
Practice Address - Country:US
Practice Address - Phone:631-942-0295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant