=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023320215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADAM RUSSELL NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2010
-----------------------------------------------------
Last Update Date | 06/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2806 N SPEER BLVD
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-457-5642
-----------------------------------------------------
Fax | 720-457-5642
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 MADISON ST SUITE 308
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80206-5418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-457-5642
-----------------------------------------------------
Fax | 720-457-5642
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | NP-990117
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------