Individual
ANTHONY J RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
2300 PARK AVE STE 203, ORANGE PARK, FL 32073-5573
(904) 634-0640
(904) 634-0203
Mailing address
6500 BOWDEN RD STE 103, JACKSONVILLE, FL 32216-8066
(904) 634-0640
(904) 634-0203
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA28155
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PTA28155
STAE LICENSE
FL
Enumeration date
01/26/2018
Last updated
01/26/2018
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