Provider Demographics
NPI:1457820631
Name:RUSS, EVANDER CONZEL (LPN)
Entity Type:Individual
Prefix:
First Name:EVANDER
Middle Name:CONZEL
Last Name:RUSS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1127
Mailing Address - Country:US
Mailing Address - Phone:585-438-1089
Mailing Address - Fax:
Practice Address - Street 1:23 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1127
Practice Address - Country:US
Practice Address - Phone:585-438-1089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-17
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334018164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse