Healthcare Provider Details

I. General information

NPI: 1114796992
Provider Name (Legal Business Name): MICHAEL WALTER RICHIE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 PIEDMONT AVE
OAKLAND CA
94611-5352
US

IV. Provider business mailing address

1104 ROSEWOOD WAY
ALAMEDA CA
94501-5636
US

V. Phone/Fax

Practice location:
  • Phone: 415-432-7899
  • Fax:
Mailing address:
  • Phone: 510-861-5595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: