Provider Demographics
NPI:1609582576
Name:SIMMONS, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:SIMMONS
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 1:8777 W MAULE AVE UNIT 2012
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4874
Mailing Address - Country:US
Mailing Address - Phone:631-404-2829
Mailing Address - Fax:
Practice Address - Street 1:1225 TRIUMPH CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7122
Practice Address - Country:US
Practice Address - Phone:248-930-2554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-1331225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant