Basic Information
| Provider Information | |||||||||
| NPI: | 1477551661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARQUARDT | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4022 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ELK HORN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7127644642 | ||||||||
| FaxNumber: | 7127644643 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 CHATBURN AVE | ||||||||
| Address2: | |||||||||
| City: | HARLAN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515372009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7127555130 | ||||||||
| FaxNumber: | 7127554445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 888 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.