Provider Demographics
NPI:1750673422
Name:CHRISTENSEN, RUSSELL D
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:D
Last Name:CHRISTENSEN
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 1:21260 N. 1450 E.
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21260 N. 1450 E.
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0383
Practice Address - Country:US
Practice Address - Phone:435-851-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1Medicaid