Provider Demographics
NPI:1013906098
Name:RUSSO, TANYA (DO)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601888
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1888
Mailing Address - Country:US
Mailing Address - Phone:704-982-2683
Mailing Address - Fax:704-512-4808
Practice Address - Street 1:105 YADKIN ST
Practice Address - Street 2:SUITE 303
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3449
Practice Address - Country:US
Practice Address - Phone:803-532-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0574208000000X
NC2015-02335208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1013906098Medicaid
NC1013906098Medicaid
NCNCU552AMedicare PIN