Provider Demographics
NPI:1306840707
Name:RICHARDS, MICHAEL D (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5056 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1521
Mailing Address - Country:US
Mailing Address - Phone:602-222-9111
Mailing Address - Fax:602-222-9333
Practice Address - Street 1:5056 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1521
Practice Address - Country:US
Practice Address - Phone:602-222-9111
Practice Address - Fax:602-222-9333
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z23910Medicare ID - Type Unspecified
S60088Medicare UPIN