Provider Demographics
NPI:1295731594
Name:RUSSON, BRIAN JOSEPH (MSPTATC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:RUSSON
Suffix:
Gender:M
Credentials:MSPTATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14841 179TH AVE SE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1161
Mailing Address - Country:US
Mailing Address - Phone:360-794-7520
Mailing Address - Fax:360-794-8947
Practice Address - Street 1:14841 179TH AVE SE
Practice Address - Street 2:SUITE 340
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1161
Practice Address - Country:US
Practice Address - Phone:360-794-7520
Practice Address - Fax:360-794-8947
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007754225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7116288Medicaid
WA7116288Medicaid