Provider Demographics
NPI:1720356496
Name:STAGG, RUSSELL (CRNA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:STAGG
Suffix:
Gender:M
Credentials:CRNA
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 2541
Mailing Address - Street 2:
Mailing Address - City:MEEKER
Mailing Address - State:CO
Mailing Address - Zip Code:81641-2541
Mailing Address - Country:US
Mailing Address - Phone:801-803-3106
Mailing Address - Fax:
Practice Address - Street 1:100 PMC DR
Practice Address - Street 2:
Practice Address - City:MEEKER
Practice Address - State:CO
Practice Address - Zip Code:81641-3181
Practice Address - Country:US
Practice Address - Phone:970-878-9740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6154226-3102163W00000X
MO2012001556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse