Provider Demographics
NPI:1811063647
Name:STOLZE, RICHARD A (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:STOLZE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 848491
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8491
Mailing Address - Country:US
Mailing Address - Phone:254-202-9330
Mailing Address - Fax:254-202-9349
Practice Address - Street 1:140 HILLCREST MEDICAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8897
Practice Address - Country:US
Practice Address - Phone:254-741-1400
Practice Address - Fax:254-741-1428
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1591363A00000X
IL085005428363A00000X
FLPA 9106393363AS0400X
TNPA0000001591363AS0400X
TXPA16710363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
ILF400253188OtherMEDICARE PTAN (INDIVIDUAL)
P78545Medicare UPIN