Provider Demographics
NPI:1114439874
Name:RUSSELL, HARRISON
Entity Type:Individual
Prefix:
First Name:HARRISON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1563 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2543
Mailing Address - Country:US
Mailing Address - Phone:415-738-7305
Mailing Address - Fax:415-554-0159
Practice Address - Street 1:1563 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2543
Practice Address - Country:US
Practice Address - Phone:415-738-7305
Practice Address - Fax:415-554-0159
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker