Provider Demographics
NPI:1386074375
Name:RUSSELL, LAURA E (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
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 1:1750 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-9540
Mailing Address - Country:US
Mailing Address - Phone:541-386-5070
Mailing Address - Fax:
Practice Address - Street 1:1750 12TH ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-9540
Practice Address - Country:US
Practice Address - Phone:541-386-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056218363A00000X
ORPA179564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant