Provider Demographics
NPI:1346591898
Name:RUSSELL, KELLY HANH (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:HANH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-2099
Mailing Address - Country:US
Mailing Address - Phone:503-769-2641
Mailing Address - Fax:503-769-3797
Practice Address - Street 1:1375 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383
Practice Address - Country:US
Practice Address - Phone:503-769-2641
Practice Address - Fax:503-769-3797
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant