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Individual

BEVERLY RUSSELL

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
PA

Contact information

Practice address
1111 TENEYCK ST, JACKSON, MI 49201-2461
(517) 205-8940
(517) 205-0108
Mailing address
1111 TENEYCK ST, JACKSON, MI 49201-2461
(517) 205-8940
(517) 205-0108

Taxonomy

Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5601004024
MI

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
1568573947
MI
Enumeration date
08/31/2006
Last updated
01/04/2021
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