Healthcare Provider Details

I. General information

NPI: 1790989093
Provider Name (Legal Business Name): RUSSELL EUGENE SANDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 NEWPORT CENTER DR SUITE 650
NEWPORT BEACH CA
92660-7610
US

IV. Provider business mailing address

450 NEWPORT CENTER DR SUTE 597
NEWPORT BEACH CA
92660-7610
US

V. Phone/Fax

Practice location:
  • Phone: 949-644-5800
  • Fax:
Mailing address:
  • Phone: 949-999-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 15863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: