Basic Information
| Provider Information | |||||||||
| NPI: | 1154971174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | GRACE BOND | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BOND | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | GRACE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2603 W JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837024714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654142656 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2327 SW 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979141851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418892340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2019 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.