Provider Demographics
NPI:1952413098
Name:PISANO, RUSSELL CHARLES (NP)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CHARLES
Last Name:PISANO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72780 COUNTRY CLUB DR STE 203
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4150
Mailing Address - Country:US
Mailing Address - Phone:760-834-3593
Mailing Address - Fax:760-674-3845
Practice Address - Street 1:72780 COUNTRY CLUB DR STE 203
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4150
Practice Address - Country:US
Practice Address - Phone:760-834-3593
Practice Address - Fax:760-674-3845
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23350111N00000X
CANP21901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP21901OtherMEDICAL LICENSE