Provider Demographics
NPI:1760024632
Name:RUSSO, ETHAN BUDD
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:BUDD
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20402 81ST AVENUE SW
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-6253
Mailing Address - Country:US
Mailing Address - Phone:206-304-4344
Mailing Address - Fax:
Practice Address - Street 1:20402 81ST AVENUE SW
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-6253
Practice Address - Country:US
Practice Address - Phone:206-304-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000183042084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00018304OtherWASHINGTON STATE MEDICAL LICENSE