Provider Demographics
NPI:1114796992
Name:RICHIE, MICHAEL WALTER
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WALTER
Last Name:RICHIE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 ROSEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5636
Mailing Address - Country:US
Mailing Address - Phone:510-861-5595
Mailing Address - Fax:
Practice Address - Street 1:2671 BLANDING AVE # AB
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1587
Practice Address - Country:US
Practice Address - Phone:415-404-3125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant