Provider Demographics
NPI:1881662385
Name:KERR, RICHARD TODD (PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:TODD
Last Name:KERR
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N WILLIAM KUMPF BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2507
Mailing Address - Country:US
Mailing Address - Phone:309-676-5546
Mailing Address - Fax:
Practice Address - Street 1:303 N WILLIAM KUMPF BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2507
Practice Address - Country:US
Practice Address - Phone:309-676-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant