Provider Demographics
NPI:1881843449
Name:LEES, RUSSELL WADE (PT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:WADE
Last Name:LEES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-3321
Mailing Address - Country:US
Mailing Address - Phone:575-374-5733
Mailing Address - Fax:
Practice Address - Street 1:301 HARDING ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3321
Practice Address - Country:US
Practice Address - Phone:575-374-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK5719OtherMEDICAID PROVIDER NUMBER