Provider Demographics
NPI:1225179849
Name:RICHARDSON, MICHAEL SHANE (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 740020
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0020
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:405-604-0708
Practice Address - Street 1:7521 SE 15TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-5425
Practice Address - Country:US
Practice Address - Phone:405-453-8004
Practice Address - Fax:405-561-4857
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2022-03-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1615363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical