Provider Demographics
NPI:1497852693
Name:KASBOW, RICHARD THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:THOMAS
Last Name:KASBOW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:THOMAS
Other - Last Name:KASBOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:9651 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-9412
Mailing Address - Country:US
Mailing Address - Phone:231-625-2148
Mailing Address - Fax:
Practice Address - Street 1:806 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1725
Practice Address - Country:US
Practice Address - Phone:989-732-7525
Practice Address - Fax:989-732-6577
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant