Basic Information
| Provider Information | |||||||||
| NPI: | 1972544559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1880 QUIET CV | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103232477 | ||||||||
| FaxNumber: | 9103235931 | ||||||||
| Practice Location | |||||||||
| Address1: | 1880 QUIET CV | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103232477 | ||||||||
| FaxNumber: | 9103235931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 104196 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 124919 | 01 | NC | PA CERTIFICATE OF REGISTR | OTHER |