MEDICARE: DOUGLAS BLANE RUSSELL PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	103359	NC

General Provider Information

NPI Number	:	1487617619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS BLANE RUSSELL PA

Provider Business Mailing Address
First Line	:	5610 GROOMETOWN RD
Second Line	:	HIGH POINT
City	:	HIGH POINT
State	:	NC
Zip	:	27263-9368
Country	:	US
Telephone Number	:	336-688-0928
Fax Number	:

Provider Business Practice Location Address
First Line	:	439 US HWY 158 WEST
Second Line	:
City	:	YANCEYVILLE
State	:	NC
Zip	:	27379
Country	:	US
Telephone Number	:	336-694-1181
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	10/05/2022

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Directions to “ DOUGLAS BLANE RUSSELL PA” Practice Location

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