Provider Demographics
NPI:1962242669
Name:RUSSON, DANIEL STARK (DPT, PT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:STARK
Last Name:RUSSON
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-423-9999
Mailing Address - Fax:208-423-9998
Practice Address - Street 1:931 CENTER ST W STE C
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341-5326
Practice Address - Country:US
Practice Address - Phone:208-423-9999
Practice Address - Fax:208-423-9998
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPT-9150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist