Provider Demographics
NPI:1336782440
Name:RUSS, MISHA (CNM)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 W RESERVE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2158
Mailing Address - Country:US
Mailing Address - Phone:406-300-4511
Mailing Address - Fax:
Practice Address - Street 1:770 W RESERVE DR STE 3
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2158
Practice Address - Country:US
Practice Address - Phone:406-300-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT146968367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife