Provider Demographics
NPI:1245315571
Name:RUSSELL, RANDY PAT (AUD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:PAT
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-3558
Mailing Address - Country:US
Mailing Address - Phone:903-927-1111
Mailing Address - Fax:432-335-0906
Practice Address - Street 1:1005 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-3558
Practice Address - Country:US
Practice Address - Phone:903-927-1111
Practice Address - Fax:903-927-0086
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50379231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80200AOtherBC/BS PROVIDER #
TX80004AMedicare UPIN