Provider Demographics
NPI:1891371167
Name:RUSSELL, ANDREW (PT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:RUSSELL
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 1:8180 STICH LN
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3153
Mailing Address - Country:US
Mailing Address - Phone:510-590-8417
Mailing Address - Fax:
Practice Address - Street 1:8180 STICH LN
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3153
Practice Address - Country:US
Practice Address - Phone:510-590-8417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist