Provider Demographics
NPI:1487329603
Name:RICHARDSON, TIMOTHY JACE (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JACE
Last Name:RICHARDSON
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 1:25 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176-8520
Mailing Address - Country:US
Mailing Address - Phone:501-658-9717
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical