Provider Demographics
NPI:1598792681
Name:RICHARD, JOHN PAUL (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:RICHARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-575-5000
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 330
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1674
Practice Address - Country:US
Practice Address - Phone:260-494-3484
Practice Address - Fax:260-969-0188
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000373363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS82833Medicare UPIN
INM400023920Medicare PIN
IN925060DDDMedicare PIN