Healthcare Provider Details

I. General information

NPI: 1972217461
Provider Name (Legal Business Name): GRAHAM E RUSSELL BSN, DNP-CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

2700 E OVERLAND RD APT C212
MERIDIAN ID
83642-8989
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-2121
  • Fax:
Mailing address:
  • Phone: 971-344-5717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN768430
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: