Provider Demographics
NPI:1487617619
Name:RUSSELL, DOUGLAS BLANE (PA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BLANE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 GROOMETOWN RD
Mailing Address - Street 2:HIGH POINT
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27263-9368
Mailing Address - Country:US
Mailing Address - Phone:336-688-0928
Mailing Address - Fax:
Practice Address - Street 1:439 US HWY 158 WEST
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379
Practice Address - Country:US
Practice Address - Phone:336-694-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2754538Medicare ID - Type Unspecified
P56443Medicare UPIN