Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | MD00025573 | WA |
NPI | 1043215809 |
---|---|
Provider Name | Byron Dale Russell |
First Address | Port Angeles, WA 98362-0146 |
Second Address | Port Angeles, WA 98362-3911 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2005 |
Last Update Date | 19/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
561060 | (05) | AZ |
A66710 | (02) |