Provider Demographics
NPI:1497472591
Name:RUSSELL, TYLER EDWARD (ARNP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:EDWARD
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BOREN AVE STE 850
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3301
Mailing Address - Country:US
Mailing Address - Phone:618-926-8065
Mailing Address - Fax:
Practice Address - Street 1:901 BOREN AVE STE 850
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3301
Practice Address - Country:US
Practice Address - Phone:618-926-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV817329163W00000X, 363L00000X
OR202111331RN163W00000X
WARN60979252163W00000X
WAAP61440563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner