Provider Demographics
NPI:1760639421
Name:RICHARDS, TYESHIA HALSELL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TYESHIA
Middle Name:HALSELL
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7098 DISTRIBUTION DR STE A
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-2879
Mailing Address - Country:US
Mailing Address - Phone:502-749-8019
Mailing Address - Fax:833-755-1833
Practice Address - Street 1:7098 DISTRIBUTION DR
Practice Address - Street 2:STE A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-2879
Practice Address - Country:US
Practice Address - Phone:502-749-8019
Practice Address - Fax:833-755-1833
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYPA1121363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100212250Medicaid