Provider Demographics
NPI:1487411757
Name:RUSSELL, BRIANA
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13167 22ND ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2529
Mailing Address - Country:US
Mailing Address - Phone:651-528-2885
Mailing Address - Fax:
Practice Address - Street 1:4201 DEAN LAKES BLVD STE 120
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2850
Practice Address - Country:US
Practice Address - Phone:952-496-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant