Basic Information
| Provider Information | |||||||||
| NPI: | 1861864852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 ANTRIM COMMONS DR | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172251623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175975553 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2015 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA057870 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C005975 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | OA003639 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1861864852 | 01 | NPI | OTHER | 103887352 | 05 | PA | MEDICAID | 14140910 | 01 | CAQH | OTHER |