Provider Demographics
NPI:1467471748
Name:RICHARDSON, COREY R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:R
Last Name:RICHARDSON
Suffix:
Gender:M
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664
Mailing Address - Country:US
Mailing Address - Phone:360-397-1500
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:501 SE 172ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9542
Practice Address - Country:US
Practice Address - Phone:360-397-1500
Practice Address - Fax:360-604-1771
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00946363A00000X
WAPA10005059363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8462046Medicaid
WA8861751Medicare PIN
WA8462046Medicaid