Provider Demographics
NPI:1326202730
Name:PORRAS, RUSSELL (PT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:PORRAS
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 1:7102 NOVAS LNDG
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-1899
Mailing Address - Country:US
Mailing Address - Phone:812-590-9181
Mailing Address - Fax:502-498-5388
Practice Address - Street 1:7102 NOVAS LNDG
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-1899
Practice Address - Country:US
Practice Address - Phone:812-590-9181
Practice Address - Fax:502-498-5388
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008378A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200952750Medicaid
IN129660012Medicare PIN