Provider Demographics
NPI:1366951394
Name:RUSSELL, MATTHEW CASSADY (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CASSADY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 EASTMOOR DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-9211
Mailing Address - Country:US
Mailing Address - Phone:828-545-9101
Mailing Address - Fax:
Practice Address - Street 1:3 E 101ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6528
Practice Address - Country:US
Practice Address - Phone:212-241-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant