Provider Demographics
NPI:1235397738
Name:WELCH, RUSSELL LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LEE
Last Name:WELCH
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N. ELM ST
Mailing Address - Street 2:STE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401
Mailing Address - Country:US
Mailing Address - Phone:336-297-2271
Mailing Address - Fax:336-297-2282
Practice Address - Street 1:510 N.ELAM AVE
Practice Address - Street 2:STE 302
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403
Practice Address - Country:US
Practice Address - Phone:336-297-2271
Practice Address - Fax:336-297-2282
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC138254363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593294Medicare UPIN