Basic Information
| Provider Information | |||||||||
| NPI: | 1568541365 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RUSSO | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 CORDATA PKWY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982267123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD60136154 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0062RU | 01 | WA | REGENCE | OTHER | 1568541365 | 05 | WA | MEDICAID | 0261505 | 01 | WA | L&I AND CRIME VICTIMS | OTHER |