Provider Demographics
NPI:1972544559
Name:RUSSELL, KRISTIN E (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:RUSSELL
Suffix:
Gender:F
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 1:1880 QUIET CV
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3857
Mailing Address - Country:US
Mailing Address - Phone:910-323-2477
Mailing Address - Fax:910-323-5931
Practice Address - Street 1:1880 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3857
Practice Address - Country:US
Practice Address - Phone:910-323-2477
Practice Address - Fax:910-323-5931
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104196363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC124919OtherPA CERTIFICATE OF REGISTR