Provider Demographics
NPI:1588820617
Name:PAPPAS, RUSSELL JENSON (LMT, NCTMB)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JENSON
Last Name:PAPPAS
Suffix:
Gender:M
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 N REDWOOD RD UNIT 46
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3766
Mailing Address - Country:US
Mailing Address - Phone:503-440-9022
Mailing Address - Fax:
Practice Address - Street 1:475 N REDWOOD RD UNIT 46
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3766
Practice Address - Country:US
Practice Address - Phone:503-440-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6254871-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist