Provider Demographics
NPI:1851610554
Name:RUSS, ROBERT J (STSA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:RUSS
Suffix:
Gender:M
Credentials:STSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W BILLY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6830
Mailing Address - Country:US
Mailing Address - Phone:928-369-8117
Mailing Address - Fax:
Practice Address - Street 1:420 W BILLY CREEK DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6830
Practice Address - Country:US
Practice Address - Phone:928-369-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist