Provider Demographics
NPI:1740304740
Name:MATHEWS, RUSSELL E (CNNP)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:101 STADIUM DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-7911
Practice Address - Country:US
Practice Address - Phone:304-598-4000
Practice Address - Fax:304-598-6061
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57233363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVMA6035511Medicare PIN
Q76414Medicare UPIN