Basic Information
| Provider Information | |||||||||
| NPI: | 1205360237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37100 N GANTZEL RD STE 201A | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851407352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803944469 | ||||||||
| FaxNumber: | 4803944520 | ||||||||
| Practice Location | |||||||||
| Address1: | 37100 N GANTZEL RD STE 201A | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851407352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803944469 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2017 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 59940 | AZ | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 59940 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.