Basic Information
| Provider Information | |||||||||
| NPI: | 1679625339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | A.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358044408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568806711 | ||||||||
| FaxNumber: | 2568806712 | ||||||||
| Practice Location | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134584185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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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 | 367H00000X | 491 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 430068034 | 01 | TX | RAILROAD MEDICARE | OTHER |