Provider Demographics
NPI:1386604015
Name:RICHARDS, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 OLD CAMP RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-1762
Mailing Address - Country:US
Mailing Address - Phone:352-259-5960
Mailing Address - Fax:352-750-1854
Practice Address - Street 1:1050 OLD CAMP RD
Practice Address - Street 2:SUITE 202
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-1762
Practice Address - Country:US
Practice Address - Phone:352-259-5960
Practice Address - Fax:352-750-1854
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY09Y6OtherBCBS FL
FL010951800Medicaid
FLE6500WMedicare PIN