Provider Demographics
NPI:1154824944
Name:RUSCONI, JOE
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:RUSCONI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 STAR GAZER LN
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-9289
Mailing Address - Country:US
Mailing Address - Phone:530-622-1685
Mailing Address - Fax:
Practice Address - Street 1:4800 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1541
Practice Address - Country:US
Practice Address - Phone:916-874-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000-00-0000OtherNA