Healthcare Provider Details

I. General information

NPI: 1295585271
Provider Name (Legal Business Name): RUSSELL LEE GARNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

IV. Provider business mailing address

PO BOX 64006
MCBH KANEOHE BAY HI
96863-4000
US

V. Phone/Fax

Practice location:
  • Phone: 808-496-3365
  • Fax:
Mailing address:
  • Phone: 808-496-3365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101286694
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: