Provider Demographics
NPI:1215681796
Name:BURGOS RUSSE, NATALIA CAROLINA
Entity type:Individual
Prefix:
First Name:NATALIA
Middle Name:CAROLINA
Last Name:BURGOS RUSSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CALLE ACERINA
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-3593
Mailing Address - Country:US
Mailing Address - Phone:787-240-5673
Mailing Address - Fax:
Practice Address - Street 1:1046 AVE HOSTOS STE 118
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-1119
Practice Address - Country:US
Practice Address - Phone:787-812-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21673336C0003X
PR2711390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy