MEDICARE: BRIAN JOSEPH RUSSON M.S.P.T.ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00007754	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295731594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN JOSEPH RUSSON M.S.P.T.ATC

Provider Business Mailing Address
First Line	:	14841 179TH AVE SE
Second Line	:	SUITE 340
City	:	MONROE
State	:	WA
Zip	:	98272-1161
Country	:	US
Telephone Number	:	360-794-7520
Fax Number	:	360-794-8947

Provider Business Practice Location Address
First Line	:	14841 179TH AVE SE
Second Line	:	SUITE 340
City	:	MONROE
State	:	WA
Zip	:	98272-1161
Country	:	US
Telephone Number	:	360-794-7520
Fax Number	:	360-794-8947

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	07/08/2007

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