=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942530647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL R. AMARU PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2010
-----------------------------------------------------
Last Update Date | 08/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2321 W DAYTON AIRPORT RD
-----------------------------------------------------
City | SHELTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98584-6319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-427-4596
-----------------------------------------------------
Fax | 360-427-4654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3357A SIMMONS MILL CT. SW
-----------------------------------------------------
City | TUMWATER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98512-7811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA10003509
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------