Healthcare Provider Details

I. General information

NPI: 1578290201
Provider Name (Legal Business Name): OLIVIA RUSSELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W MEDICAL CENTER BLVD STE 406
WEBSTER TX
77598-4009
US

IV. Provider business mailing address

PO BOX 58538
WEBSTER TX
77598-8538
US

V. Phone/Fax

Practice location:
  • Phone: 281-332-3507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16135
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: