1972544559 NPI number — KRISTIN E RUSSELL PA-C

Table of content: KRISTIN E RUSSELL PA-C (NPI 1972544559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972544559 NPI number — KRISTIN E RUSSELL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
KRISTIN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972544559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1880 QUIET CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-3857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-323-2477
Provider Business Mailing Address Fax Number:
910-323-5931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1880 QUIET CV
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-3857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-323-2477
Provider Business Practice Location Address Fax Number:
910-323-5931
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  104196 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 124919 . This is a "PA CERTIFICATE OF REGISTR" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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