Provider Demographics
NPI:1295711562
Name:HUTCHISON, RICHARD GLEN (PA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GLEN
Last Name:HUTCHISON
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 1:11364 QUEENSLAND CT
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-8238
Mailing Address - Country:US
Mailing Address - Phone:405-259-9617
Mailing Address - Fax:
Practice Address - Street 1:1000 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-3252
Practice Address - Country:US
Practice Address - Phone:405-271-5582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN