Provider Demographics
NPI:1326417353
Name:RUSSELL, ADAM GREGORY (CRNA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:GREGORY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PAGE ST
Mailing Address - Street 2:
Mailing Address - City:BROWNVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04414-3523
Mailing Address - Country:US
Mailing Address - Phone:207-943-3097
Mailing Address - Fax:
Practice Address - Street 1:11 PAGE ST
Practice Address - Street 2:
Practice Address - City:BROWNVILLE
Practice Address - State:ME
Practice Address - Zip Code:04414-3523
Practice Address - Country:US
Practice Address - Phone:207-943-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA153027367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered