Provider Demographics
NPI:1043332497
Name:RUSSELL, JEFFREY WYAN (MHS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WYAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140386
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99514-0386
Mailing Address - Country:US
Mailing Address - Phone:907-277-0972
Mailing Address - Fax:
Practice Address - Street 1:2741 DEBARR RD
Practice Address - Street 2:SUITE C-308
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2953
Practice Address - Country:US
Practice Address - Phone:907-272-3366
Practice Address - Fax:907-272-0269
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant