Provider Demographics
NPI:1659353357
Name:STAIE, RICHARD JOHN (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:STAIE
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 1:610 ACADIA DR # 7131
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-5986
Mailing Address - Country:US
Mailing Address - Phone:770-634-1287
Mailing Address - Fax:
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:770-920-6413
Practice Address - Fax:678-838-2532
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003918363A00000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002432BMedicaid
GA491431789AMedicaid
GA491431789AMedicaid
GA32BBBJRMedicare PIN
GAGRP6182Medicare PIN