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General NPI Number Information
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NPI Number | 1235163858
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Entity Type | Individual
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Provider Name | RUSSEL GROVER LADWIG PAC
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Gender | Male
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 03/23/2022
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Provider Practice Location Address
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Address Line | 9300 VALLEY CHILDRENS PL
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City | MADERA
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State | CA
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Zip | 93636-8762
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Country | US
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Telephone | 559-353-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 644 E PINTAIL CIRCLE
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City | FRESNO
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State | CA
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Zip | 93720-1266
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Country | US
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Telephone | 599-433-9282
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA17196
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License Number State | CA
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