Provider Demographics
NPI:1851435580
Name:EBBERT, RICHARD A (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:EBBERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14381 FORD RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-9562
Mailing Address - Country:US
Mailing Address - Phone:440-298-3714
Mailing Address - Fax:
Practice Address - Street 1:2422 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4985
Practice Address - Country:US
Practice Address - Phone:440-998-3376
Practice Address - Fax:440-997-5751
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant