Provider Demographics
NPI:1659037950
Name:RUSSO, NICHOLAS (PT, DPT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41690 COLADA CT
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-0338
Mailing Address - Country:US
Mailing Address - Phone:516-643-5027
Mailing Address - Fax:
Practice Address - Street 1:72880 FRED WARING DR STE B7
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-9375
Practice Address - Country:US
Practice Address - Phone:760-340-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic