Provider Demographics
NPI:1396300505
Name:THURMAN, RUSSELL (PTA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:THURMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 THORNBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-8737
Mailing Address - Country:US
Mailing Address - Phone:417-894-7052
Mailing Address - Fax:
Practice Address - Street 1:305 THORNBROOKE DR
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-8737
Practice Address - Country:US
Practice Address - Phone:417-894-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080342252081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine