Provider Demographics
NPI:1417351446
Name:RICHARDSON, SANDRA DELVALLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:DELVALLE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:318-629-4833
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA09380363A00000X
LAPA200735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant