Provider Demographics
NPI:1649325176
Name:RUSS, ANNALARSA WALKER (MPT)
Entity type:Individual
Prefix:
First Name:ANNALARSA
Middle Name:WALKER
Last Name:RUSS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ANNALARSA
Other - Middle Name:LAETAZELLE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:139 FIDDLERS RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655
Mailing Address - Country:US
Mailing Address - Phone:828-437-1786
Mailing Address - Fax:828-438-4032
Practice Address - Street 1:139 FIDDLERS RUN BLVD
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655
Practice Address - Country:US
Practice Address - Phone:828-437-1786
Practice Address - Fax:828-438-4032
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10782225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10782OtherPT LICENSE
NC2502830Medicare PIN