Provider Demographics
NPI:1699701540
Name:RUSSELL, EMILY A (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:A
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 1:148 LINDEN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6902
Mailing Address - Country:US
Mailing Address - Phone:540-504-0075
Mailing Address - Fax:540-678-9025
Practice Address - Street 1:1867 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2801
Practice Address - Country:US
Practice Address - Phone:540-667-8724
Practice Address - Fax:540-723-0741
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001174363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV7283B566Medicare PIN