Provider Demographics
NPI:1093889289
Name:RICHARDSON, RYAN CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:CHRISTOPHER
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-3720
Mailing Address - Country:US
Mailing Address - Phone:877-897-7477
Mailing Address - Fax:877-755-1030
Practice Address - Street 1:3771 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-3720
Practice Address - Country:US
Practice Address - Phone:877-897-7477
Practice Address - Fax:877-755-1030
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004930363A00000X
OH50002540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA29243Medicare PIN