Provider Demographics
NPI:1457895054
Name:RUSS, ANDREW WRAY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:WRAY
Last Name:RUSS
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 1:223 BELMONT CT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7118
Mailing Address - Country:US
Mailing Address - Phone:909-644-6420
Mailing Address - Fax:
Practice Address - Street 1:124 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5250
Practice Address - Country:US
Practice Address - Phone:909-798-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01024357133V00000X
CAPA53942363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered