Provider Demographics
NPI:1104861368
Name:RICHINS, STEPHEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:RICHINS
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 1:1448 E CENTER ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4105
Mailing Address - Country:US
Mailing Address - Phone:208-234-1300
Mailing Address - Fax:208-234-1333
Practice Address - Street 1:711 RIGBY LAKE DR
Practice Address - Street 2:STE. 114
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5229
Practice Address - Country:US
Practice Address - Phone:208-234-1300
Practice Address - Fax:208-234-1333
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-931363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME328390099Medicaid
ME970027996OtherRAILROAD MEDICARE
IDP00993652OtherMEDICARE RAILROAD
ME328390099Medicaid