Provider Demographics
NPI:1003676651
Name:RUSSELL-BOGAN, KATE LOUISE
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:LOUISE
Last Name:RUSSELL-BOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E VIRGINIA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5865
Mailing Address - Country:US
Mailing Address - Phone:084-938-2113
Mailing Address - Fax:408-579-6143
Practice Address - Street 1:160 E VIRGINIA ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5865
Practice Address - Country:US
Practice Address - Phone:084-938-2113
Practice Address - Fax:408-579-6143
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program