Healthcare Provider Details

I. General information

NPI: 1720356496
Provider Name (Legal Business Name): RUSSELL STAGG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PMC DR
MEEKER CO
81641-3181
US

IV. Provider business mailing address

PO BOX 2541
MEEKER CO
81641-2541
US

V. Phone/Fax

Practice location:
  • Phone: 970-878-9740
  • Fax:
Mailing address:
  • Phone: 801-803-3106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6154226-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2012001556
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: