Provider Demographics
NPI:1013376649
Name:RUSSO, ANDREW PETER (ATC, SCAT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:PETER
Last Name:RUSSO
Suffix:
Gender:M
Credentials:ATC, SCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 POINCARE BND
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6926
Mailing Address - Country:US
Mailing Address - Phone:757-635-9512
Mailing Address - Fax:
Practice Address - Street 1:301 MEETING ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29424-1552
Practice Address - Country:US
Practice Address - Phone:757-635-9512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC20432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program