Provider Demographics
NPI:1598543621
Name:RUSSELL, LILY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:MARIE
Last Name:RUSSELL
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 1:1109 TURNER ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-6426
Mailing Address - Country:US
Mailing Address - Phone:207-513-2896
Mailing Address - Fax:
Practice Address - Street 1:15 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7997
Practice Address - Country:US
Practice Address - Phone:207-621-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant