Provider Demographics
NPI:1255121638
Name:RICHARDS, MICHAEL DALLIN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALLIN
Last Name:RICHARDS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 COPPER CREEK TRL APT 9103
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-9327
Mailing Address - Country:US
Mailing Address - Phone:435-225-5827
Mailing Address - Fax:
Practice Address - Street 1:10850 COPPER CREEK TRL APT 9103
Practice Address - Street 2:
Practice Address - City:MAIZE
Practice Address - State:KS
Practice Address - Zip Code:67101-9327
Practice Address - Country:US
Practice Address - Phone:435-225-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical