Basic Information
| Provider Information | |||||||||
| NPI: | 1669629549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAUFFMAN | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2008 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 11293 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1981 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PAC0411 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 71034 | 05 | ND | MEDICAID | 71305 | 05 | ND | MEDICAID |