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General NPI Number Information
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NPI Number | 1942645411
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Entity Type | Individual
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Provider Name | RUSSELL JOHN KINSEY PA-C
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Gender | Male
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Dates
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Enumeration Date | 05/09/2013
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Last Update Date | 05/09/2013
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Provider Practice Location Address
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Address Line | 517 N MAIN ST
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City | ANNA
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State | IL
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Zip | 62906-1668
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Country | US
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Telephone | 618-833-4511
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Fax | 618-833-4183
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Provider Business Mailing Address
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Address Line | 4971 S PALMER AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65804-7482
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Country | US
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Telephone | 417-380-1444
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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 | 085.004652
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License Number State | IL
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