Provider Demographics
NPI:1962242669
Name:RUSSON, DANIEL STARK (DPT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:STARK
Last Name:RUSSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 W QUINN RD TRLR 222
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2883
Mailing Address - Country:US
Mailing Address - Phone:801-836-5334
Mailing Address - Fax:
Practice Address - Street 1:1800 FLANDRO DR STE 190
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4940
Practice Address - Country:US
Practice Address - Phone:208-233-2248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID9150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist