Healthcare Provider Details

I. General information

NPI: 1710711841
Provider Name (Legal Business Name): ANDREW KARL RUSSELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HURLEY PLZ
FLINT MI
48503-5902
US

IV. Provider business mailing address

11433 GRAND BLVD STE 1
GRAND BLANC MI
48439-3320
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-9355
  • Fax:
Mailing address:
  • Phone: 810-498-7780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012701
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: