NPI 1003092594

Justin Jake Russell, LMP

Practitioner Specialist Leavenworth, WA

Practice location

Address: 22470 Humphrey Dr, Leavenworth, WA 98826-9240
Phone: (253) 389-7510
Mailing address: PO Box 475, Leavenworth, WA 98826-0475

Registered specialties

Specialist Primary

Other Service Providers Taxonomy 174400000X Licence MA00024875 (WA)

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Registry record

NPI: 1003092594
Entity type: Individual
Sex (as registered): Male
NPI issued: 14 Jan 2008
Record last updated: 14 Aug 2008

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.