Provider Demographics
NPI:1356304810
Name:ULSTAD, RICHARD DOUGLAS (PAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DOUGLAS
Last Name:ULSTAD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 GLEN MEADE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6024
Mailing Address - Country:US
Mailing Address - Phone:910-763-6251
Mailing Address - Fax:910-763-7408
Practice Address - Street 1:1905 GLEN MEADE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6024
Practice Address - Country:US
Practice Address - Phone:910-763-6251
Practice Address - Fax:910-763-7408
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P50627Medicare UPIN
2754529KMedicare ID - Type Unspecified