Provider Demographics
NPI:1912985995
Name:RICHARDS, MICHAEL P (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:RICHARDS
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 1:5 NEPONSET ST
Mailing Address - Street 2:WOT 2ND FL, STE C203
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-425-5446
Mailing Address - Fax:508-425-5951
Practice Address - Street 1:385 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2498
Practice Address - Country:US
Practice Address - Phone:508-425-5446
Practice Address - Fax:508-425-5951
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110124109AMedicaid
83 00653OtherEVERCARE
AP1319OtherMEDICARE B
AP1319OtherBLUE SHIELD INDEMNITY
AP1319OtherMEDICARE B
AP1319OtherBLUE SHIELD INDEMNITY