Provider Demographics
NPI:1932209558
Name:RUSSELL, KIMBERLY ANNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:JUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PC-A
Mailing Address - Street 1:921 NE 13TH ST # 2A-133
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5007
Mailing Address - Country:US
Mailing Address - Phone:405-456-4367
Mailing Address - Fax:405-456-1504
Practice Address - Street 1:VAMC 921 NE 13TH STREET
Practice Address - Street 2:2A-137
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-456-3896
Practice Address - Fax:405-456-1504
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA744363A00000X
OK744363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant