Healthcare Provider Details

I. General information

NPI: 1962559567
Provider Name (Legal Business Name): RUSSELL PEARL PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 G ST
SPRINGFIELD OR
97477-4112
US

IV. Provider business mailing address

505 S 336TH ST SUITE 600
FEDERAL WAY WA
98003-6328
US

V. Phone/Fax

Practice location:
  • Phone: 541-726-4510
  • Fax:
Mailing address:
  • Phone: 253-838-6180
  • Fax: 253-838-6418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA10005135
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01307
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: