Provider Demographics
NPI:1417684010
Name:RUSSO, JOHN KERCH (RN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KERCH
Last Name:RUSSO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3162 MONROE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4551
Mailing Address - Country:US
Mailing Address - Phone:301-312-4623
Mailing Address - Fax:
Practice Address - Street 1:1045 9TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5504
Practice Address - Country:US
Practice Address - Phone:619-235-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95284726163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95284726OtherRN- CALIFORNIA BRN