Provider Demographics
NPI:1437117546
Name:RICHARDSON, KELLY D (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
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 1:1871 EVELYN BYRD AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-3487
Mailing Address - Country:US
Mailing Address - Phone:540-564-5800
Mailing Address - Fax:540-564-5801
Practice Address - Street 1:1871 EVELYN BYRD AVE
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-3487
Practice Address - Country:US
Practice Address - Phone:540-564-5800
Practice Address - Fax:540-564-5801
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437117546Medicaid
VA010117810Medicaid
VAP00126087OtherRAILROAD MEDICARE
Q20013Medicare UPIN