# FORM ASSOCIATES, P.A.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1740971605
- **Authorized official:** TROY RUSSELL MD (OWNER)
- **Authorized official phone:** (617) 505-1520

## Contact information

- **Practice address:** 801 E DOUGLAS AVE FL 2, WICHITA, KS 67202-3548
- **Practice address phone:** (617) 505-1520
- **Practice address fax:** (617) 928-8401
- **Mailing address:** 109 STATE ST., 5TH FL, BOSTON, MA 02109-2906
- **Mailing address phone:** (617) 505-1520
- **Mailing address fax:** (617) 928-8401

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | NULL | Yes |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | — | Yes |
| 261QH0100X | Health Service Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 05/19/2023
- **Last updated:** 03/18/2026