Provider Demographics
NPI:1285916825
Name:RICHARDSON, THERESA JEANETTE (PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:JEANETTE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:JEANETTE
Other - Last Name:CYR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-261-1960
Mailing Address - Fax:586-261-1961
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-261-1960
Practice Address - Fax:586-261-1961
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant