Provider Demographics
NPI:1649496274
Name:GREGORY, RICHARD (MPSA, PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MPSA, PA-C
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:29039 HOLLOW OAK CT
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301
Mailing Address - Country:US
Mailing Address - Phone:805-371-4499
Mailing Address - Fax:
Practice Address - Street 1:29039 HOLLOW OAK CT
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301
Practice Address - Country:US
Practice Address - Phone:818-438-7882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17030OtherGROUP PTAN
CA15519OtherPHYSICIAN ASSISTANT
CA15519OtherPHYSICIAN ASSISTANT