Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | ML60962149 | WA |
Y | 208600000X | Surgeon | ML60962149 | WA |
NPI | 1003374265 |
---|---|
Provider Name | Michael Russell |
First Address | Chicago, IL 60612-3806 |
Second Address | Seattle, WA 98122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2019 |
Last Update Date | 22/06/2019 |