Provider Demographics
NPI:1194819748
Name:FLYGARE, RICHARD ANDREW (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANDREW
Last Name:FLYGARE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2288 MERRITT CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-665-7546
Mailing Address - Fax:208-667-4607
Practice Address - Street 1:2288 MERRIT CREEK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-665-7546
Practice Address - Fax:208-667-4607
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805947800Medicaid
ID1666864Medicare ID - Type Unspecified
ID805947800Medicaid