Provider Demographics
NPI:1447244355
Name:RICHARDSON, KERI LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KERI
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:LYNN
Other - Last Name:MULLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10930 N TATUM BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6069
Mailing Address - Country:US
Mailing Address - Phone:602-263-7600
Mailing Address - Fax:602-212-0365
Practice Address - Street 1:10930 N TATUM BLVD
Practice Address - Street 2:STE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6069
Practice Address - Country:US
Practice Address - Phone:602-263-7600
Practice Address - Fax:602-212-0365
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP72081Medicare UPIN
AZ78078Medicare ID - Type Unspecified