Provider Demographics
NPI:1093255275
Name:AHLSTROM, RICHARD THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:THOMAS
Last Name:AHLSTROM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5979 DESERT STORM AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5514
Mailing Address - Country:US
Mailing Address - Phone:270-412-9191
Mailing Address - Fax:
Practice Address - Street 1:5979 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5514
Practice Address - Country:US
Practice Address - Phone:270-412-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant