Provider Demographics
NPI:1194829283
Name:RICHARDS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 MEMORIAL DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 MEMORIAL DR
Practice Address - Street 2:SUITE 2
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7057
Practice Address - Country:US
Practice Address - Phone:814-623-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002177363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
061668248OtherBCBS
061668248OtherBCBS