Provider Demographics
NPI:1881895530
Name:MCGLOTHLIN, RICHARD DARRELL (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DARRELL
Last Name:MCGLOTHLIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2367
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-2367
Mailing Address - Country:US
Mailing Address - Phone:916-622-3609
Mailing Address - Fax:916-780-1679
Practice Address - Street 1:1501 SECRET RAVINE PARKWAY
Practice Address - Street 2:UNIT 527
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-6005
Practice Address - Country:US
Practice Address - Phone:916-622-3609
Practice Address - Fax:916-780-1679
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19185363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant