Provider Demographics
NPI:1841450764
Name:RUSSO, PAUL M (PTA)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 LOS PUEBLOS DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5321
Mailing Address - Country:US
Mailing Address - Phone:805-384-1950
Mailing Address - Fax:
Practice Address - Street 1:2641 S C ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-4502
Practice Address - Country:US
Practice Address - Phone:805-487-7840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT4221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant