Provider Demographics
NPI:1770633349
Name:TASSINARI, RUSSELL (MPT, ATC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:TASSINARI
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 MISSION BLVD
Mailing Address - Street 2:STE. 4
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2541
Mailing Address - Country:US
Mailing Address - Phone:858-581-6900
Mailing Address - Fax:858-581-6999
Practice Address - Street 1:4747 MISSION BLVD
Practice Address - Street 2:STE. 4
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-2541
Practice Address - Country:US
Practice Address - Phone:858-581-6900
Practice Address - Fax:858-581-6999
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20254Medicare ID - Type UnspecifiedPHYSICAL THERAPIST