Healthcare Provider Details

I. General information

NPI: 1235163858
Provider Name (Legal Business Name): RUSSEL GROVER LADWIG PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8762
US

IV. Provider business mailing address

644 E PINTAIL CIRCLE
FRESNO CA
93720-1266
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-3000
  • Fax:
Mailing address:
  • Phone: 599-433-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: