Healthcare Provider Details

I. General information

NPI: 1295336956
Provider Name (Legal Business Name): RYAN RUSSO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2020
Last Update Date: 11/07/2020
Certification Date: 11/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 SOTO ST
SAN DIEGO CA
92107-1410
US

IV. Provider business mailing address

2376 SOTO ST
SAN DIEGO CA
92107-1410
US

V. Phone/Fax

Practice location:
  • Phone: 414-803-6018
  • Fax:
Mailing address:
  • Phone: 414-803-6018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number4605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: