MEDICARE: OLIVIA RUSSELL PA-C

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

General Provider Information

NPI Number	:	1578290201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA RUSSELL PA-C

Provider Business Mailing Address
First Line	:	1919 NORTH LOOP W STE 218
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1366
Country	:	US
Telephone Number	:	713-862-5797
Fax Number	:	713-862-0166

Provider Business Practice Location Address
First Line	:	1919 NORTH LOOP W STE 218
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1366
Country	:	US
Telephone Number	:	713-862-5797
Fax Number	:	713-862-0166

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

Provider Enumeration Date	:	08/03/2022
Last Update Date	:	05/10/2024

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Directions to “ OLIVIA RUSSELL PA-C” Practice Location

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