Provider Demographics
NPI:1699163147
Name:RICHARDS, CRAIG
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-0500
Mailing Address - Country:US
Mailing Address - Phone:716-699-9032
Mailing Address - Fax:716-699-9035
Practice Address - Street 1:390 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750
Practice Address - Country:US
Practice Address - Phone:716-526-0156
Practice Address - Fax:716-708-1578
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003464363A00000X
PAMA057397363A00000X
NY022362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant