Healthcare Provider Details

I. General information

NPI: 1992053847
Provider Name (Legal Business Name): RUSSELL LARDER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 MARTIN LUTHER KING JR WAY
SEATTLE WA
98108
US

IV. Provider business mailing address

1776 S COLUMBIAN WAY
SEATTLE WA
98108-1534
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-5325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN00138452
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: