Provider Demographics
NPI:1225016488
Name:MIKAMI, RUSSELL (PT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:MIKAMI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 N SULLIVAN RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8528
Mailing Address - Country:US
Mailing Address - Phone:509-928-3443
Mailing Address - Fax:509-891-5591
Practice Address - Street 1:618 N SULLIVAN RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8528
Practice Address - Country:US
Practice Address - Phone:509-928-3443
Practice Address - Fax:509-891-5591
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025208 PT00003614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7107627Medicaid
WA7107627Medicaid