Provider Demographics
NPI:1275584070
Name:RUSSELL, JOHN CALVIN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CALVIN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2201 N BROADWELL AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-2153
Mailing Address - Country:US
Mailing Address - Phone:308-382-3660
Mailing Address - Fax:308-395-3214
Practice Address - Street 1:2201 N BROADWELL AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2153
Practice Address - Country:US
Practice Address - Phone:308-382-3660
Practice Address - Fax:308-395-3214
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078557539Medicaid
NES92536Medicare UPIN
NE47078557539Medicaid