Provider Demographics
NPI:1871576439
Name:RUSSELL, ROGER JAY (PT)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:JAY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 STONE ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4169
Mailing Address - Country:US
Mailing Address - Phone:509-529-5977
Mailing Address - Fax:
Practice Address - Street 1:124 STONE ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4169
Practice Address - Country:US
Practice Address - Phone:509-529-5977
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist