Healthcare Provider Details

I. General information

NPI: 1154250926
Provider Name (Legal Business Name): BLAKE JAMES RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E MCDOWELL RD
PHOENIX AZ
85006-2612
US

IV. Provider business mailing address

390 W WISTERIA PL
CHANDLER AZ
85248-4031
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-2000
  • Fax:
Mailing address:
  • Phone: 208-305-3779
  • Fax: 208-305-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number340170
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: