Provider Demographics
NPI:1861825127
Name:RICHARDS, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
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 1:963 TOWN CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8254
Mailing Address - Country:US
Mailing Address - Phone:386-774-9880
Mailing Address - Fax:386-774-2898
Practice Address - Street 1:963 TOWN CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8254
Practice Address - Country:US
Practice Address - Phone:386-774-9880
Practice Address - Fax:386-774-2898
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
02004368OtherAMERIGROUP
FLOO9981300Medicaid
FLHN901ZMedicare PIN