Provider Demographics
NPI:1295482784
Name:ARAYATA, RUSSELL P
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:P
Last Name:ARAYATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43290 CHRISTY ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-3172
Mailing Address - Country:US
Mailing Address - Phone:510-894-5254
Mailing Address - Fax:
Practice Address - Street 1:43290 CHRISTY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-3172
Practice Address - Country:US
Practice Address - Phone:510-894-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWLS7556332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA07251971OtherOTHER