Provider Demographics
NPI:1487933834
Name:RUSSO, MAIRA ANABEL (PA-C)
Entity type:Individual
Prefix:MS
First Name:MAIRA
Middle Name:ANABEL
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-342-2439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00258900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant