Provider Demographics
NPI:1760475354
Name:DODSON, RUSSELL (PAC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DODSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W UTOPIA RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4171
Mailing Address - Country:US
Mailing Address - Phone:602-214-6148
Mailing Address - Fax:602-214-6149
Practice Address - Street 1:34975 N NORTH VALLEY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-4028
Practice Address - Country:US
Practice Address - Phone:623-295-4820
Practice Address - Fax:623-295-4830
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1015363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS58425Medicare UPIN
AZ70126Medicare ID - Type Unspecified