Provider Demographics
NPI:1205092327
Name:SMITH, RUSSELL R (PA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 ALTAMESA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-5475
Mailing Address - Country:US
Mailing Address - Phone:817-854-9969
Mailing Address - Fax:817-845-9965
Practice Address - Street 1:5900 ALTAMESA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-5475
Practice Address - Country:US
Practice Address - Phone:817-854-9969
Practice Address - Fax:817-845-9965
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05791363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283600901Medicaid
TXTXB132403Medicare PIN
TX558295YKPWMedicare PIN