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1962242669 NPI number — DANIEL STARK RUSSON DPT, PT

NPI Number: 1962242669
Health Care Provider/Practitioner: DANIEL STARK RUSSON DPT, PT

Information about “1962242669” NPI (DANIEL STARK RUSSON DPT, PT) exists in 1962242669 in HTML format HTML  |  1962242669 in plain Text format TXT  |  1962242669 in PDF (Portable Document Format) PDF  |  1962242669 in an XML format XML  formats.

NPI Number : 1962242669 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1962242669",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "RUSSON",
    "FirstName": "DANIEL",
    "MiddleName": "STARK",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "DPT, PT",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "1411 FALLS AVE E STE 401",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "TWIN FALLS",
    "MailingAddressStateName": "ID",
    "MailingAddressPostalCode": "83301-3455",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "208-423-9999",
    "MailingAddressFaxNumber": "208-423-9998",
    "FirstLinePracticeLocationAddress": "931 CENTER ST W STE C",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "KIMBERLY",
    "PracticeLocationAddressStateName": "ID",
    "PracticeLocationAddressPostalCode": "83341-5326",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "208-423-9999",
    "PracticeLocationAddressFaxNumber": "208-423-9998",
    "EnumerationDate": "05/29/2024",
    "LastUpdateDate": "06/24/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "225100000X",
        "TaxonomyName": "Physical Therapist",
        "LicenseNumber": "PT-9150",
        "LicenseNumberStateCode": "ID",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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