Provider Demographics
NPI:1760497283
Name:RICHARDSON, MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:VANDERHOOF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 S LIMESTONE CTW 324
Mailing Address - Street 2:DIVISION OF CARDIOLOGY
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0200
Mailing Address - Country:US
Mailing Address - Phone:859-323-3976
Mailing Address - Fax:859-257-6060
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:DIVISION OF CARDIOLOGY
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0200
Practice Address - Country:US
Practice Address - Phone:859-323-3976
Practice Address - Fax:859-257-6060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0987654310Medicaid
KYP400034181Medicare PIN
KY212428Medicare ID - Type Unspecified