Basic Information
| Provider Information | |||||||||
| NPI: | 1912361163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | RUSSEL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8717 W 110TH ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134282951 | ||||||||
| FaxNumber: | 9134282951 | ||||||||
| Practice Location | |||||||||
| Address1: | 2316 E MEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641321136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134282900 | ||||||||
| FaxNumber: | 9134282951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2009030213 | MO | N | Nursing Service Providers | Registered Nurse | 367500000X | 43-557426-091 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 2016019123 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.