Provider Demographics
NPI:1497894745
Name:OLIVER, RUSSELL DALE (CRNA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DALE
Last Name:OLIVER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:RUSTY
Other - Middle Name:
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1504 LOCUST CIR SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-2005
Mailing Address - Country:US
Mailing Address - Phone:256-539-7363
Mailing Address - Fax:
Practice Address - Street 1:1874 BELTLINE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-5514
Practice Address - Country:US
Practice Address - Phone:256-301-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-076076367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL52959OtherCRNA LICENSE
AL1-076076OtherALABAMA STATE LICENSE
AL076076OtherRN LICENSE