Provider Demographics
NPI:1790895779
Name:RICHARDS, TODD BRUCE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:BRUCE
Last Name:RICHARDS
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 1:224 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:MI
Mailing Address - Zip Code:49635-9658
Mailing Address - Country:US
Mailing Address - Phone:231-352-2200
Mailing Address - Fax:231-352-2232
Practice Address - Street 1:224 PARK AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:MI
Practice Address - Zip Code:49635-9036
Practice Address - Country:US
Practice Address - Phone:231-352-2200
Practice Address - Fax:231-352-2232
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000841363A00000X
MI5601009216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P26875Medicare UPIN
RIPA35991Medicare PIN