Provider Demographics
NPI:1417377953
Name:MCDANIEL, RUSSELL (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:520 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2588
Mailing Address - Country:US
Mailing Address - Phone:231-876-6527
Mailing Address - Fax:231-876-6519
Practice Address - Street 1:1035 E WILCOX AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8794
Practice Address - Country:US
Practice Address - Phone:231-689-5943
Practice Address - Fax:231-689-1590
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601007005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant