Provider Demographics
NPI:1235941444
Name:RUSSO, CECILIA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:CECILIA
Middle Name:ROSE
Last Name:RUSSO
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 1:1620 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1334
Mailing Address - Country:US
Mailing Address - Phone:570-336-3718
Mailing Address - Fax:
Practice Address - Street 1:501 S WASHINGTON AVE STE 1000
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-3805
Practice Address - Country:US
Practice Address - Phone:570-941-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA066309363A00000X
PAOA007149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant