Provider Demographics
NPI:1356636443
Name:PINCOCK, RUSSELL B (NP-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:B
Last Name:PINCOCK
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA CREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84534-0130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 S 300 W
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3921
Practice Address - Country:US
Practice Address - Phone:435-651-3700
Practice Address - Fax:435-678-0608
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49201274405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily