Provider Demographics
NPI:1962562793
Name:DAVIS, RUSSELL ERIC (PT)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ERIC
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:R.
Other - Middle Name:ERIC
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2005 ESKRIDGE BLVD SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-3704
Mailing Address - Country:US
Mailing Address - Phone:253-381-7602
Mailing Address - Fax:
Practice Address - Street 1:PHYSICAL THERAPY CLINIC, GRAFENWEOHR, BMEDDAC
Practice Address - Street 2:BLDG 476, ROOM 107
Practice Address - City:APO AE
Practice Address - State:NY
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:253-968-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist