Provider Demographics
NPI:1508007238
Name:RICHARDSON, WENDY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:MARIE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:MARIE
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670 COUNTY RD 83
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:CA
Practice Address - Zip Code:96015
Practice Address - Country:US
Practice Address - Phone:530-233-4641
Practice Address - Fax:530-233-2830
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant