Provider Demographics
NPI:1407366453
Name:RUSSELL, LUKE ANDREW (PA)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:ANDREW
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-2532
Mailing Address - Fax:
Practice Address - Street 1:7050 AIR DEPOT BLVD BLDG 1040
Practice Address - Street 2:
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-8716
Practice Address - Country:US
Practice Address - Phone:405-734-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant