Provider Demographics
NPI:1922508795
Name:RUSSELL, BRYCE ELTIN (ACNP-AG)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:ELTIN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:ACNP-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 HERITAGE COLONY DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-3206
Mailing Address - Country:US
Mailing Address - Phone:832-457-5179
Mailing Address - Fax:
Practice Address - Street 1:11914 ASTORIA BLVD STE 590
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6079
Practice Address - Country:US
Practice Address - Phone:832-871-4099
Practice Address - Fax:281-994-7449
Is Sole Proprietor?:No
Enumeration Date:2018-02-17
Last Update Date:2018-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136036363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care