Provider Demographics
NPI:1326711748
Name:RUSSELL, RYAN PIERCE
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PIERCE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 RONCEVERTE AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1322
Mailing Address - Country:US
Mailing Address - Phone:205-910-6785
Mailing Address - Fax:
Practice Address - Street 1:400 JEFFERSON ST. NORTH
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-2490
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program