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General NPI Number Information
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NPI Number | 1235648916
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Entity Type | Individual
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Provider Name | RUSSELL K WALSTON CRNA
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Gender | Male
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Dates
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Enumeration Date | 09/25/2017
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Last Update Date | 04/23/2025
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Provider Practice Location Address
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Address Line | 1551 E TANGERINE RD
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City | ORO VALLEY
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State | AZ
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Zip | 85755-6213
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Country | US
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Telephone | 520-901-3500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6210
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City | FARMINGTON
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State | NM
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Zip | 87499-6210
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Country | US
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Telephone | 505-609-2258
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Fax | 505-609-2259
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 8000945-3102
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | CRNA-01530
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License Number State | NM
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