Provider Demographics
NPI:1427301084
Name:RUSSO, BRIAN (PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 NW SAMMAMISH RD
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8940
Mailing Address - Country:US
Mailing Address - Phone:425-394-0600
Mailing Address - Fax:
Practice Address - Street 1:751 NE BLAKEY DRIVE
Practice Address - Street 2:SWEDISH MEDICAL CENTER
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-394-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60310413363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant