Provider Demographics
NPI:1568075950
Name:DIMMIG-RUSSELL, JOSHUA SANDERS (APRN)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:SANDERS
Last Name:DIMMIG-RUSSELL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1587 RED FOX RUN SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2465
Mailing Address - Country:US
Mailing Address - Phone:716-912-5284
Mailing Address - Fax:
Practice Address - Street 1:10680 MEDLOCK BRIDGE RD STE 102
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8420
Practice Address - Country:US
Practice Address - Phone:770-389-9116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA232569363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner