Provider Demographics
NPI:1487211306
Name:RUSSELL, GARRETT ANDREW
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:ANDREW
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N SILVER SPRINGS BLVD APT 404
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-6004
Mailing Address - Country:US
Mailing Address - Phone:918-638-8377
Mailing Address - Fax:
Practice Address - Street 1:102 N DENVER AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74103-1806
Practice Address - Country:US
Practice Address - Phone:918-582-1200
Practice Address - Fax:918-560-1399
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator