Basic Information
| Provider Information | |||||||||
| NPI: | 1952413098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PISANO | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72780 COUNTRY CLUB DR STE 203 | ||||||||
| Address2: | |||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922704150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608343593 | ||||||||
| FaxNumber: | 7606743845 | ||||||||
| Practice Location | |||||||||
| Address1: | 72780 COUNTRY CLUB DR STE 203 | ||||||||
| Address2: | |||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922704150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608343593 | ||||||||
| FaxNumber: | 7606743845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC23350 | CA | N | Chiropractic Providers | Chiropractor | 363LF0000X | NP21901 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP21901 | 01 | CA | MEDICAL LICENSE | OTHER |