Healthcare Provider Details

I. General information

NPI: 1770061640
Provider Name (Legal Business Name): SAMUEL EDWARD RUSSETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 NE OAK VIEW DR
VANCOUVER WA
98662-6157
US

IV. Provider business mailing address

12901 NE 28TH ST APT 133
VANCOUVER WA
98682-1229
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax:
Mailing address:
  • Phone: 700-969-0488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: