Provider Demographics
NPI:1063743557
Name:GANA, RUSSELL MATTHEW (DC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MATTHEW
Last Name:GANA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 FORTVIEW RD STE 104
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7600
Mailing Address - Country:US
Mailing Address - Phone:512-829-1549
Mailing Address - Fax:
Practice Address - Street 1:1825 FORTVIEW RD STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7600
Practice Address - Country:US
Practice Address - Phone:512-829-1549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11283111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor