Basic Information
| Provider Information | |||||||||
| NPI: | 1487617619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | BLANE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5610 GROOMETOWN RD | ||||||||
| Address2: | HIGH POINT | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272639368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366880928 | ||||||||
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| Practice Location | |||||||||
| Address1: | 439 US HWY 158 WEST | ||||||||
| Address2: | |||||||||
| City: | YANCEYVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366941181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 103359 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.