Provider Demographics
NPI:1639808306
Name:RUSSELL, JEREMY LAWRENCE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:LAWRENCE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1389
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:LA
Mailing Address - Zip Code:70711-1389
Mailing Address - Country:US
Mailing Address - Phone:985-320-2195
Mailing Address - Fax:
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1436
Practice Address - Country:US
Practice Address - Phone:985-345-2700
Practice Address - Fax:985-230-6653
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1196694363A00000X
LA332993363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1639808306OtherNPI