1932209558 NPI number — MS. KIMBERLY ANNE RUSSELL PA-C

Table of content: MS. KIMBERLY ANNE RUSSELL PA-C (NPI 1932209558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932209558 NPI number — MS. KIMBERLY ANNE RUSSELL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
KIMBERLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
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:
JUST
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PC-A
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932209558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 NE 13TH ST # 2A-133
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73104-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-456-4367
Provider Business Mailing Address Fax Number:
405-456-1504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VAMC 921 NE 13TH STREET
Provider Second Line Business Practice Location Address:
2A-137
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-456-3896
Provider Business Practice Location Address Fax Number:
405-456-1504
Provider Enumeration Date:
09/24/2006

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: 363A00000X , with the licence number:  PA744 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 744 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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