Provider Demographics
NPI:1720096449
Name:DOYLE, RUSSELL WAYNE (PA)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:WAYNE
Last Name:DOYLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 SISTER MARY COLUMBA DR
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-4327
Mailing Address - Country:US
Mailing Address - Phone:530-528-8899
Mailing Address - Fax:530-528-8898
Practice Address - Street 1:2540 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:530-528-8899
Practice Address - Fax:530-528-8898
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11684363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27575ZOtherGROUP ID NUMBER
CAP32782Medicare UPIN
CAZZZ27575ZOtherGROUP ID NUMBER