Provider Demographics
NPI:1710096458
Name:EDISON, RICHARD G (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:EDISON
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 1:1225 SE COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-9721
Practice Address - Country:US
Practice Address - Phone:509-516-1101
Practice Address - Fax:509-516-1102
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
WAPA10004152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1017094Medicaid
WAP01256590OtherRR MEDICARE
WA219156OtherL&I
WA8944040OtherCV
WA1710096458Medicaid
WA315750OtherL&I POST 7/21/13
WA315750OtherL&I POST 7/21/13