Provider Demographics
NPI:1427130822
Name:RICHARDSON, THERESA (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CANAL VIEW BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2808
Mailing Address - Country:US
Mailing Address - Phone:585-338-2700
Mailing Address - Fax:585-242-9663
Practice Address - Street 1:140 CANAL VIEW BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2808
Practice Address - Country:US
Practice Address - Phone:585-338-2700
Practice Address - Fax:585-242-9663
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004950363A00000X, 363AM0700X
NY4950363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
918196001OtherCOMMUNITY BLUE
PA0169OtherPREFERRED CARE
PO19004950OtherBLUE CHOICE
000918196001OtherHEALTHNOW
PA0169OtherPREFERRED CARE
PA0169OtherPREFERRED CARE