Provider Demographics
NPI:1972056588
Name:RUSSELL, JACOB TROY (CRNA)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:TROY
Last Name:RUSSELL
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 1:823 W SIERRA CIR
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-6602
Mailing Address - Country:US
Mailing Address - Phone:480-209-9285
Mailing Address - Fax:
Practice Address - Street 1:807 S PONDEROSA ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5542
Practice Address - Country:US
Practice Address - Phone:928-472-1273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-31
Last Update Date:2016-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA1226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered