Basic Information
| Provider Information | |||||||||
| NPI: | 1962559567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEARL | ||||||||
| FirstName: | RUSSELL | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1460 G ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974774112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417264510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | PA10005135 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | PA01307 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0216544 | 01 | WA | LIWA | OTHER | 3454PE | 01 | WA | BSWA | OTHER | 8471328 | 05 | WA | MEDICAID | P91043 | 01 | WA | UPIN | OTHER | PEA1967 | 01 | WA | NPI LOGIN | OTHER |