Provider Demographics
NPI:1699176255
Name:ROBINSON, RUSSELL SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:SCOTT
Last Name:ROBINSON
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 1:1108 W INDIAN SCHOOL RD
Mailing Address - Street 2:STE B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3107
Mailing Address - Country:US
Mailing Address - Phone:602-773-5600
Mailing Address - Fax:602-773-5601
Practice Address - Street 1:1108 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3107
Practice Address - Country:US
Practice Address - Phone:602-773-5600
Practice Address - Fax:602-773-5601
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ173607OtherPTAN
AZ975247Medicaid