Provider Demographics
NPI:1215689658
Name:VAN GELDER, RUSSEL
Entity type:Individual
Prefix:
First Name:RUSSEL
Middle Name:
Last Name:VAN GELDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 TALBOT RD S STE 200
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5738
Mailing Address - Country:US
Mailing Address - Phone:425-690-3400
Mailing Address - Fax:425-690-0600
Practice Address - Street 1:3915 TALBOT RD S STE 200
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5738
Practice Address - Country:US
Practice Address - Phone:425-690-3400
Practice Address - Fax:425-690-0600
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61261029363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily