Provider Demographics
NPI:1508856410
Name:ALLEN, RICHARD DEREK (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DEREK
Last Name:ALLEN
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 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:1201 S MILLER ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3201
Practice Address - Country:US
Practice Address - Phone:509-665-6130
Practice Address - Fax:509-665-6052
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004806363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA289199OtherWVH LNI
WA1508856410Medicaid
WAP01381482OtherRR MEDICARE WVH
WA1508856410Medicaid