Basic Information
| Provider Information | |||||||||
| NPI: | 1811063647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOLZE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 5651 FRIST BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370762058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153914545 | ||||||||
| FaxNumber: | 6153914546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085005428 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA 9106393 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 1591 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 206147 | 01 | IL | MEDICARE PTAN (GROUP) | OTHER | F400253188 | 01 | IL | MEDICARE PTAN (INDIVIDUAL) | OTHER |