Provider Demographics
NPI:1316604937
Name:RUSSO, ANTONINO ROBERTO
Entity type:Individual
Prefix:
First Name:ANTONINO
Middle Name:ROBERTO
Last Name:RUSSO
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 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-647-0024
Mailing Address - Fax:208-647-0239
Practice Address - Street 1:1945 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2714
Practice Address - Country:US
Practice Address - Phone:208-647-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist