Provider Demographics
NPI:1952811051
Name:SOUTHWELL, RICKEY LEE JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:LEE
Last Name:SOUTHWELL
Suffix:JR
Gender:
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 1:2400 WASHINGTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2814
Mailing Address - Country:US
Mailing Address - Phone:530-530-2267
Mailing Address - Fax:
Practice Address - Street 1:1742 OREGON ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1717
Practice Address - Country:US
Practice Address - Phone:530-646-7269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54920363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant