Provider Demographics
NPI:1265206916
Name:RUSSO, TAYLOR MARIE I (MSPAS, PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:RUSSO
Suffix:I
Gender:F
Credentials:MSPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 CUBA AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4909
Mailing Address - Country:US
Mailing Address - Phone:347-737-9488
Mailing Address - Fax:
Practice Address - Street 1:65 BROADWAY FL 21
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2510
Practice Address - Country:US
Practice Address - Phone:212-818-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031037-01363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical