Provider Demographics
NPI:1164965109
Name:RICHARDS, NICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RICHARDS
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 1:1 BOONE RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1894
Mailing Address - Country:US
Mailing Address - Phone:360-475-4000
Mailing Address - Fax:
Practice Address - Street 1:1 BOONE RD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1894
Practice Address - Country:US
Practice Address - Phone:360-475-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 363AM0700X
UT11469067-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11469067-8906OtherUTAH CS 2-5 LICENSE
UT11469067-1206OtherUTAH LICENSE
UT11469067-1206OtherUTAH LICENSE