Provider Demographics
NPI:1205360237
Name:RUSSELL, NATHAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:E
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37100 N GANTZEL RD STE 201A
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-7352
Mailing Address - Country:US
Mailing Address - Phone:480-394-4469
Mailing Address - Fax:480-394-4520
Practice Address - Street 1:37100 N GANTZEL RD STE 201A
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7352
Practice Address - Country:US
Practice Address - Phone:480-394-4469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59940208M00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program