Provider Demographics
NPI:1750628798
Name:RUSSELL, DENISA KAVIKOVA (PA)
Entity type:Individual
Prefix:
First Name:DENISA
Middle Name:KAVIKOVA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N COLEMAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-2304
Mailing Address - Country:US
Mailing Address - Phone:972-469-2626
Mailing Address - Fax:
Practice Address - Street 1:821 N COLEMAN ST STE 100
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-2304
Practice Address - Country:US
Practice Address - Phone:972-469-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08261363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280807YKY6Medicare PIN