Provider Demographics
NPI:1942645411
Name:KINSEY, RUSSELL JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JOHN
Last Name:KINSEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4971 S PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7482
Mailing Address - Country:US
Mailing Address - Phone:417-380-1444
Mailing Address - Fax:
Practice Address - Street 1:517 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1668
Practice Address - Country:US
Practice Address - Phone:618-833-4511
Practice Address - Fax:618-833-4183
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant