Provider Demographics
NPI:1790989093
Name:SANDERS, RUSSELL EUGENE
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EUGENE
Last Name:SANDERS
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 1:450 NEWPORT CENTER DR
Mailing Address - Street 2:SUTE 597
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7610
Mailing Address - Country:US
Mailing Address - Phone:949-999-3646
Mailing Address - Fax:
Practice Address - Street 1:450 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 650
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7610
Practice Address - Country:US
Practice Address - Phone:949-644-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 15863OtherLICENSE