Provider Demographics
NPI:1942699574
Name:DEL ROSARIO, RUSSELL
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DEL ROSARIO
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 1:4053 LONE TREE WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-6210
Mailing Address - Country:US
Mailing Address - Phone:925-756-3499
Mailing Address - Fax:
Practice Address - Street 1:4053 LONE TREE WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-6210
Practice Address - Country:US
Practice Address - Phone:925-756-3499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002097363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily