Provider Demographics
NPI: | 1780644476 |
---|---|
Name: | RICHARDS, JAMES WILLIAM (PAC) |
Entity Type: | Individual |
Prefix: | |
First Name: | JAMES |
Middle Name: | WILLIAM |
Last Name: | RICHARDS |
Suffix: | |
Gender: | M |
Credentials: | PAC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 113 COMANCHE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT MEADE |
Mailing Address - State: | SD |
Mailing Address - Zip Code: | 57741-1002 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 605-347-2511 |
Mailing Address - Fax: | 605-720-7236 |
Practice Address - Street 1: | 113 COMANCHE RD |
Practice Address - Street 2: | |
Practice Address - City: | FORT MEADE |
Practice Address - State: | SD |
Practice Address - Zip Code: | 57741-1002 |
Practice Address - Country: | US |
Practice Address - Phone: | 605-347-2511 |
Practice Address - Fax: | 605-720-7236 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-25 |
Last Update Date: | 2024-03-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SD | 0508 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SD | 6824452 | Medicaid | |
SD | 0041154 | Other | WELLMARK BCBS PIN |
0977050001 | Medicare NSC | ||
P00011054 | Medicare PIN | ||
SD | 0041154 | Other | WELLMARK BCBS PIN |
SD | 6824452 | Medicaid |