Provider Demographics
NPI:1902905979
Name:RUSSO, LEONARD WILLIAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:WILLIAM
Last Name:RUSSO
Suffix:
Gender:M
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 1:34461 MORNINGDALE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-5743
Mailing Address - Country:US
Mailing Address - Phone:586-264-5946
Mailing Address - Fax:
Practice Address - Street 1:22255 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3710
Practice Address - Country:US
Practice Address - Phone:248-849-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical