Provider Demographics
NPI:1811911688
Name:RUSSELL, PAUL A
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2278 ALBERT PIKE RD STE B
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-4157
Mailing Address - Country:US
Mailing Address - Phone:501-767-0808
Mailing Address - Fax:
Practice Address - Street 1:2278 ALBERT PIKE RD STE B
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-4157
Practice Address - Country:US
Practice Address - Phone:501-767-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 1269174400000X
ARAT325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U837Medicare ID - Type Unspecified