Provider Demographics
NPI:1992021315
Name:RUSSELL, BRIAN D (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 LINCOLN ST APT 505
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-1777
Mailing Address - Country:US
Mailing Address - Phone:865-806-9161
Mailing Address - Fax:
Practice Address - Street 1:143 LONGWATER DR
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1683
Practice Address - Country:US
Practice Address - Phone:781-878-5200
Practice Address - Fax:781-878-6750
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14835363LF0000X
MARN2330343363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523401Medicaid
VAP01504956OtherRAILROAD MEDICARE
VA1992021315Medicaid
VAVVF957AMedicare PIN
TN103I509478Medicare PIN
TN1523401Medicaid