MEDICARE: JAMES D RUSSELL PA-C

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
1	363AM0700X	Medical Physician Assistant	000148	TX

General Provider Information

NPI Number	:	1831276476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES D RUSSELL PA-C

Provider Business Mailing Address
First Line	:	2318 PAT BOOKER RD
Second Line	:
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78148-3229
Country	:	US
Telephone Number	:	210-241-2198
Fax Number	:	210-659-7668

Provider Business Practice Location Address
First Line	:	2318 PAT BOOKER RD
Second Line	:
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78148-3229
Country	:	US
Telephone Number	:	210-659-0323
Fax Number	:	210-659-7668

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	01/19/2016

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