Provider Demographics
NPI:1437314366
Name:RUSSELL, MARK WILLIAM (PTA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SCHOONER LANDING DR
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-8833
Mailing Address - Country:US
Mailing Address - Phone:252-632-4137
Mailing Address - Fax:
Practice Address - Street 1:108 SCHOONER LANDING DR
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-8833
Practice Address - Country:US
Practice Address - Phone:252-632-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3666172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker