Provider Demographics
NPI:1457934366
Name:RUSSO, ASHLEY TAYLOR (DPM)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:TAYLOR
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 STATION PLZ N STE 305
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3893
Mailing Address - Country:US
Mailing Address - Phone:516-663-4798
Mailing Address - Fax:
Practice Address - Street 1:1111 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1617
Practice Address - Country:US
Practice Address - Phone:516-742-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN007383213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery