Provider Demographics
NPI:1073259479
Name:RICHARDSON, KATIE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:15507 S NORMANDIE AVE # 231
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4028
Mailing Address - Country:US
Mailing Address - Phone:714-292-7359
Mailing Address - Fax:
Practice Address - Street 1:21250 HAWTHORNE BLVD STE 430
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5511
Practice Address - Country:US
Practice Address - Phone:310-326-3066
Practice Address - Fax:310-326-3068
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA60727363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant