Provider Demographics
NPI:1891252680
Name:FIKE, RUSSELL DAVID (PA-C)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:DAVID
Last Name:FIKE
Suffix:
Gender:M
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 1:18200 W 119TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-9507
Mailing Address - Country:US
Mailing Address - Phone:913-355-8350
Mailing Address - Fax:
Practice Address - Street 1:18200 W 119TH ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-9507
Practice Address - Country:US
Practice Address - Phone:913-355-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56568363A00000X, 363AM0700X
KS15-02556363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical