Provider Demographics
NPI:1811373293
Name:RUSSELL, ADAM
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:RUSSELL
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 1:234 W GREENWAY ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2641
Mailing Address - Country:US
Mailing Address - Phone:316-788-6734
Mailing Address - Fax:316-788-4529
Practice Address - Street 1:234 W GREENWAY ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2641
Practice Address - Country:US
Practice Address - Phone:316-788-6734
Practice Address - Fax:316-788-4529
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-05077225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist