Provider Demographics
NPI:1659154706
Name:NIFFENEGGER, RUSSELL JAMES (NP)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JAMES
Last Name:NIFFENEGGER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:RUSSELL
Other - Middle Name:MILTON
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1079 DEER TRAIL LN NE
Mailing Address - Street 2:
Mailing Address - City:THOMPSON
Mailing Address - State:ND
Mailing Address - Zip Code:58278-9400
Mailing Address - Country:US
Mailing Address - Phone:701-740-9272
Mailing Address - Fax:
Practice Address - Street 1:2100 S COLUMBIA RD STE 114
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5895
Practice Address - Country:US
Practice Address - Phone:701-516-4637
Practice Address - Fax:877-651-1381
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR42886363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily