Provider Demographics
NPI:1639491194
Name:RUSSO, MATTHEW R (LPN)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:R
Last Name:RUSSO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-2901
Mailing Address - Country:US
Mailing Address - Phone:914-835-6464
Mailing Address - Fax:
Practice Address - Street 1:41 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-2901
Practice Address - Country:US
Practice Address - Phone:914-835-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261151164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse