Provider Demographics
NPI:1679625339
Name:RUSSELL, NORMAN ALAN (AA)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:ALAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-4408
Mailing Address - Country:US
Mailing Address - Phone:256-880-6711
Mailing Address - Fax:256-880-6712
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-458-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX491367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX430068034OtherRAILROAD MEDICARE
TX83619HMedicare PIN