Provider Demographics
NPI:1215147756
Name:HUCKERT, RUSSELL EDWARD (PT)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EDWARD
Last Name:HUCKERT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3106
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-3106
Mailing Address - Country:US
Mailing Address - Phone:907-543-4309
Mailing Address - Fax:
Practice Address - Street 1:700 CHIEF EDDIE HOFFMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6359
Practice Address - Fax:907-543-6850
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT1569Medicaid