Provider Demographics
NPI:1437372927
Name:RICHARDSON, JOSHUA (MT)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 NE BURNSIDE RD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-6722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1217 NE BURNSIDE RD
Practice Address - Street 2:SUITE 502
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-6722
Practice Address - Country:US
Practice Address - Phone:503-492-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist