Provider Demographics
NPI:1992124622
Name:RICHARDSON, RUNAKO (NP)
Entity type:Individual
Prefix:
First Name:RUNAKO
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RUNAKO
Other - Middle Name:
Other - Last Name:JADAGU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3901 AIRPORT FWY STE 230
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-6091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3707 E SOUTHERN AVE STE 1018
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6201
Practice Address - Country:US
Practice Address - Phone:602-878-7702
Practice Address - Fax:602-878-7702
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ291371363LP0808X
TXAP125465363L00000X, 363LP0808X
TX125465363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350960YKQLMedicare PIN
TX350960YKP5Medicare PIN