Basic Information
| Provider Information | |||||||||
| NPI: | 1003012980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT,DPT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3005 W HORIZON RIDGE PKWY STE 101 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890525030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028402500 | ||||||||
| FaxNumber: | 7252341515 | ||||||||
| Practice Location | |||||||||
| Address1: | 3005 W HORIZON RIDGE PKWY STE 101 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890525030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028402500 | ||||||||
| FaxNumber: | 7252341515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2143 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 2143 | NV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.