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General NPI Number Information
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NPI Number | 1790647360
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Entity Type | Individual
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Provider Name | JONATHAN RUSSO RN
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Gender | Male
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Dates
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Enumeration Date | 12/02/2025
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Last Update Date | 12/02/2025
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Provider Practice Location Address
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Address Line | 280 HOME OLU PL.
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City | KAUNAKAKAI
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State | HI
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Zip | 96748
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Country | US
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Telephone | 808-553-5331
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Fax |
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Provider Business Mailing Address
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Address Line | 41 FLAX ISLE DR
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City | LITTLE EGG HARBOR TWP
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State | NJ
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Zip | 08087-2316
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Country | US
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Telephone | 808-553-5331
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN121387
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License Number State | HI
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