Provider Demographics
NPI:1164783544
Name:STILLWAGON, RICHELLE A (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHELLE
Middle Name:A
Last Name:STILLWAGON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 COCHISE DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-9720
Mailing Address - Country:US
Mailing Address - Phone:602-743-5967
Mailing Address - Fax:
Practice Address - Street 1:33501 1ST WAY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6208
Practice Address - Country:US
Practice Address - Phone:206-223-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR73383207R00000X
MT104726207W00000X
WAMD60894494207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine