Provider Demographics
NPI:1700539905
Name:RICHARDSON, WESTON TYLER (PA)
Entity Type:Individual
Prefix:
First Name:WESTON
Middle Name:TYLER
Last Name:RICHARDSON
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 1:1600 S 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4011
Mailing Address - Country:US
Mailing Address - Phone:928-348-4000
Mailing Address - Fax:
Practice Address - Street 1:1600 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4011
Practice Address - Country:US
Practice Address - Phone:928-348-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8944363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical