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NPI Code Detail

MEDICARE: BLAKE JAMES RUSSELL

MEDICARE: BLAKE JAMES RUSSELL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WC0200XCritical Care Medicine Registered Nurse12458171-3102UT

General Provider Information

NPI Number : 1154250926
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAKE JAMES RUSSELL
Provider Business Mailing Address
First Line : 576 W KELLYS CV
Second Line :
City : WOODLAND HILLS
State : UT
Zip : 84653-5901
Country : US
Telephone Number : 208-305-3779
Fax Number : 208-305-3779
Provider Business Practice Location Address
First Line : 1111 E MCDOWELL RD
Second Line :
City : PHOENIX
State : AZ
Zip : 85006-2612
Country : US
Telephone Number : 602-839-2000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/18/2026
Last Update Date : 05/18/2026

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Directions to “ BLAKE JAMES RUSSELL ” Practice Location

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