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Individual

DR. TANYA RUSSO

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
DO

Contact information

Practice address
105 YADKIN ST, SUITE 303, ALBEMARLE, NC 28001-3449
(803) 532-2208
Mailing address
PO BOX 601888, CHARLOTTE, NC 28260-1888
(704) 982-2683
(704) 512-4808

Taxonomy

Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
0574
SC
208000000X
Pediatrics Physician
2015-02335
NC

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
1013906098
NC
Enumeration date
10/21/2005
Last updated
02/02/2017
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