Basic Information
| Provider Information | |||||||||
| NPI: | 1174922447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
| FaxNumber: | 6164866702 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 OAK ST UNIT 11 | ||||||||
| Address2: | |||||||||
| City: | BIG RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315921002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2014 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601007115 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.