Provider Demographics
NPI:1770761348
Name:RUSSELL, JOHN (ARNP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12470 TELECOM DR STE 300W
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:813-871-8200
Mailing Address - Fax:813-357-5501
Practice Address - Street 1:12470 TELECOM DR STE 300W
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0904
Practice Address - Country:US
Practice Address - Phone:813-871-8200
Practice Address - Fax:813-357-5501
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1818802363L00000X
FLARNP1818802363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8836XMedicare PIN