Individual
MR. JEREMY LAWRENCE RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
15790 PAUL VEGA MD DR, HAMMOND, LA 70403-1436
(985) 345-2700
(985) 230-6653
Mailing address
PO BOX 1389, ALBANY, LA 70711-1389
(985) 320-2195
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
1196694
LA
363AS0400X
Surgical Physician Assistant
Primary
332993
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1639808306
NPI
LA
Enumeration date
06/08/2022
Last updated
06/08/2023
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