Provider Demographics
NPI:1841358603
Name:RUSSO, HEATHER LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYNN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:WYKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3520 LONGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8400
Mailing Address - Country:US
Mailing Address - Phone:330-239-0780
Mailing Address - Fax:
Practice Address - Street 1:224 W LORAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1087
Practice Address - Country:US
Practice Address - Phone:440-775-1881
Practice Address - Fax:440-744-5707
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant