Provider Demographics
NPI:1265845283
Name:RUSSELL, CHRISTOPHER C (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:C
Last Name:RUSSELL
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:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38503-0938
Mailing Address - Country:US
Mailing Address - Phone:931-783-2334
Mailing Address - Fax:931-783-2253
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4294
Practice Address - Country:US
Practice Address - Phone:931-783-2334
Practice Address - Fax:931-783-2253
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA9892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant