Provider Demographics
NPI:1275583247
Name:RICHARDSON, THEA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:THEA
Middle Name:A
Last Name:RICHARDSON
Suffix:
Gender:F
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 1:749 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824-1405
Mailing Address - Country:US
Mailing Address - Phone:814-661-3733
Mailing Address - Fax:
Practice Address - Street 1:1036 PARK AVENUE EXT
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-4028
Practice Address - Country:US
Practice Address - Phone:814-765-9677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS000518L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical