Provider Demographics
NPI:1043218720
Name:RUSSELL, CHARLES MARK (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARK
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6157 NW LOOP 410
Mailing Address - Street 2:STE. 124
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-3302
Mailing Address - Country:US
Mailing Address - Phone:210-523-1411
Mailing Address - Fax:210-523-9307
Practice Address - Street 1:6157 NW LOOP 410
Practice Address - Street 2:STE. 124
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-3302
Practice Address - Country:US
Practice Address - Phone:210-523-1411
Practice Address - Fax:210-523-9307
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA00353363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX312676501OtherWELLMED MEDICAID
TXTXB153718OtherWELLMED MEDICARE