Provider Demographics
NPI:1063664605
Name:RUSSO, SEAN MICHAEL (CPO)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:MICHAEL
Last Name:RUSSO
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-7503
Mailing Address - Country:US
Mailing Address - Phone:727-327-3332
Mailing Address - Fax:727-327-7304
Practice Address - Street 1:3611 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-7503
Practice Address - Country:US
Practice Address - Phone:727-327-3332
Practice Address - Fax:727-327-7304
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR177174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist