Basic Information
| Provider Information | |||||||||
| NPI: | 1780957738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAUPIN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707440834 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 MED TECH PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232328301 | ||||||||
| FaxNumber: | 4232328304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2012 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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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 | 363AS0400X | 2111 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 2111 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100200110 | 05 | KY | MEDICAID | 1780957738 | 05 | VA | MEDICAID | 4322825 | 01 | TN | BCBS - SURGERY | OTHER | 1527379 | 05 | TN | MEDICAID | 4322824 | 01 | TN | BCBS | OTHER |