Provider Demographics
NPI:1447552963
Name:RUSSELL, CYNTHIA (RPAC)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6449 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4053
Mailing Address - Country:US
Mailing Address - Phone:801-458-7724
Mailing Address - Fax:
Practice Address - Street 1:129 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4039
Practice Address - Country:US
Practice Address - Phone:718-821-0643
Practice Address - Fax:718-628-4123
Is Sole Proprietor?:No
Enumeration Date:2010-12-04
Last Update Date:2010-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014487-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical