Provider Demographics
NPI:1861864852
Name:RICHARDSON, KEVIN (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:
Practice Address - Street 1:24 ANTRIM COMMONS DR
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:PA
Practice Address - Zip Code:17225-1623
Practice Address - Country:US
Practice Address - Phone:717-593-0512
Practice Address - Fax:717-839-6810
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057870363A00000X, 363AM0700X
MDC005975363A00000X
PAOA003639363A00000X, 363AM0700X
MDC05975363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
14140910OtherCAQH
1861864852OtherNPI
PA103887352Medicaid