Provider Demographics
NPI:1477551661
Name:MARQUARDT, RUSSELL GORDON SR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:GORDON
Last Name:MARQUARDT
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:4022 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELK HORN
Mailing Address - State:IA
Mailing Address - Zip Code:51531
Mailing Address - Country:US
Mailing Address - Phone:712-764-4642
Mailing Address - Fax:712-764-4643
Practice Address - Street 1:1220 CHATBURN AVE
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-2009
Practice Address - Country:US
Practice Address - Phone:712-755-5130
Practice Address - Fax:712-755-4445
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-12-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA888363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAR03132Medicare UPIN