Provider Demographics
NPI:1619496999
Name:RUSSELL, RUBY LORETTA (PA-C)
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:LORETTA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18700 N 64TH DR STE 301
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7114
Mailing Address - Country:US
Mailing Address - Phone:602-841-0741
Mailing Address - Fax:
Practice Address - Street 1:18700 N 64TH DR STE 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7114
Practice Address - Country:US
Practice Address - Phone:602-841-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant