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NPI Code Detail

MEDICARE: RICHARD R RUSSELL PA

MEDICARE: RICHARD R RUSSELL PA
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
1363A00000XPhysician Assistant1016831206UT

General Provider Information

NPI Number : 1184647786
Entity Type Code : Individual
Provider Name (Legal Business Name) : RICHARD R RUSSELL PA
Provider Business Mailing Address
First Line : PO BOX 27128
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84127-0128
Country : US
Telephone Number : 801-387-8100
Fax Number :
Provider Business Practice Location Address
First Line : 1915 W 5950 S
Second Line :
City : ROY
State : UT
Zip : 84067-1454
Country : US
Telephone Number : 801-387-8100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/25/2006
Last Update Date : 07/09/2008

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Directions to “ RICHARD R RUSSELL PA” Practice Location

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