Provider Demographics
NPI:1710005426
Name:ALLEN, RICHARD WARREN (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WARREN
Last Name:ALLEN
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 1:2525 W GREENWAY RD STE 125
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4226
Mailing Address - Country:US
Mailing Address - Phone:480-640-0513
Mailing Address - Fax:602-532-7997
Practice Address - Street 1:2525 W GREENWAY RD STE 125
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-4226
Practice Address - Country:US
Practice Address - Phone:480-640-0513
Practice Address - Fax:602-532-7997
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2336363AM0700X
AZ3336363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2336OtherLICENSE
AZ698092Medicaid
AZZ153187Medicare PIN