Provider Demographics
NPI:1093244303
Name:RUSSO, ANDREA (CRM)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5257 NE MARTIN LUTHER KING JR STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3283
Mailing Address - Country:US
Mailing Address - Phone:503-851-0059
Mailing Address - Fax:503-430-5403
Practice Address - Street 1:5257 NE MARTIN LUTHER KING JR STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3283
Practice Address - Country:US
Practice Address - Phone:503-851-0059
Practice Address - Fax:503-430-5403
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17-CRM-099175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist