Provider Demographics
NPI:1073881793
Name:MOBLEY, RUSSELL G (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:G
Last Name:MOBLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 N TURNER AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5524
Mailing Address - Country:US
Mailing Address - Phone:190-972-1587
Mailing Address - Fax:
Practice Address - Street 1:730 NORTH TURNER AVE
Practice Address - Street 2:APT 2
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764
Practice Address - Country:US
Practice Address - Phone:909-728-1587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant