Basic Information
| Provider Information | |||||||||
| NPI: | 1467471748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603971500 | ||||||||
| FaxNumber: | 3606041771 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SE 172ND AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986849542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603971500 | ||||||||
| FaxNumber: | 3606041771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00946 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA10005059 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8462046 | 05 | WA | MEDICAID |