Individual
MR. JONATHAN FORREST RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
671 SW MAIN ST, WINSTON, OR 97496-6571
(541) 492-4550
(541) 679-2005
Mailing address
671 SW MAIN ST, WINSTON, OR 97496-6571
(541) 492-4550
(541) 492-4553
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
161337
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03-1815
MEDICARE
—
01
—
03-1820
MEDICARE
—
05
—
364775
—
AZ
01
—
Z132429
MEDICARE
—
01
—
Z139132
MEDICARE
—
01
—
ZFQ31815
MEDICARE
—
01
—
ZFQ31820
MEDICARE
—
Enumeration date
10/17/2007
Last updated
03/05/2025
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