Provider Demographics
NPI:1295587293
Name:BROXSON, RUSSELL KEVIN JR (FNP BC)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:KEVIN
Last Name:BROXSON
Suffix:JR
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 1:5228 MEDICINE BOW ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-8149
Mailing Address - Country:US
Mailing Address - Phone:850-449-4801
Mailing Address - Fax:
Practice Address - Street 1:14114 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-1219
Practice Address - Country:US
Practice Address - Phone:850-675-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031992363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily