Provider Demographics
NPI:1336157833
Name:EDGERLY, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:EDGERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 S 40TH AVE
Mailing Address - Street 2:STE A
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3800
Mailing Address - Country:US
Mailing Address - Phone:509-823-4650
Mailing Address - Fax:509-823-4652
Practice Address - Street 1:1420 AHTANUM RIDGE DR
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1839
Practice Address - Country:US
Practice Address - Phone:509-454-7700
Practice Address - Fax:509-454-7710
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8220840Medicaid
WA8220840Medicaid
G8800118Medicare PIN