Individual ProviderRussell JohnsonPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address2801 W Kinnickinnic River Pkwy Ste 370, Milwaukee, WI 53215-3678(414) 649-7900(800) 326-2250PECOS EnrollmentBased on the most recent information from CMS, provider Russell Johnson is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records yesterday at 11:26 AM.Profile DetailsProvider ID1710345483Provider TypeIndividualFull NameJohnson, RussellGenderMaleSole ProprietorNoEnumeration Date2/9/2016Last Updated6/3/2025Contact InformationPractice LocationPractice Address2801 W Kinnickinnic River Pkwy Ste 370, Milwaukee, WI 53215-3678Phone(414) 649-7900FaxUnlisted FaxMailing LocationMailing AddressPO Box 735044, Chicago, IL 60673-5044Phone(800) 326-2250FaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode363A00000XPrimaryDescriptionPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersLicense4642WisconsinProvider IdentifiersIDDescriptionIssuerID100088079DescriptionMedicaidIssuerUnlistedWisconsin