Provider Demographics
NPI:1457405144
Name:RUSS, SHANNAN R (NP)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:R
Last Name:RUSS
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:R
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1005 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-1007
Mailing Address - Country:US
Mailing Address - Phone:607-734-3968
Mailing Address - Fax:833-450-5884
Practice Address - Street 1:1005 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1007
Practice Address - Country:US
Practice Address - Phone:607-734-3968
Practice Address - Fax:833-450-5884
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02001921Medicaid
NY02001921Medicaid