Provider Demographics
NPI:1831248715
Name:RICHARDSON, KELLY A (PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:237 RIDGELAND ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-4510
Mailing Address - Country:US
Mailing Address - Phone:409-781-1014
Mailing Address - Fax:
Practice Address - Street 1:2830 CALDER ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1809
Practice Address - Country:US
Practice Address - Phone:409-781-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02363363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88N836OtherBLUE CROSS BLUE SHIELD
TX88N836OtherBLUE CROSS BLUE SHIELD
TXS92224Medicare UPIN