Provider Demographics
NPI:1922323773
Name:RUSSO, ALFRED JOHN (DAOM, LAC)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:JOHN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3933 STONE WAY N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8017
Mailing Address - Country:US
Mailing Address - Phone:206-861-5580
Mailing Address - Fax:844-787-4718
Practice Address - Street 1:3933 STONE WAY N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8017
Practice Address - Country:US
Practice Address - Phone:206-861-5580
Practice Address - Fax:844-787-4718
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3036171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist