Provider Demographics
NPI:1255412318
Name:RUSSELL, BRENT CHARLES (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:CHARLES
Last Name:RUSSELL
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 1:12685 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-2933
Mailing Address - Country:US
Mailing Address - Phone:419-865-4448
Mailing Address - Fax:
Practice Address - Street 1:43145 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1955
Practice Address - Country:US
Practice Address - Phone:589-997-5048
Practice Address - Fax:589-997-5049
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002647363AM0700X
OH50-00-0863363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH55.000448OtherCERTIFICATE TO PRESCRIBE
MI5601002647OtherPAIN MANAGEMENT
MI5601002647OtherPAIN MANAGEMENT