Healthcare Provider Details

I. General information

NPI: 1174031660
Provider Name (Legal Business Name): KEIFER DEWAYNE RICHARDSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 WALTON WAY
AUGUSTA GA
30904-2305
US

IV. Provider business mailing address

526 RICHLAND AVE W
AIKEN SC
29801-3828
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-1590
  • Fax:
Mailing address:
  • Phone: 803-648-3130
  • Fax: 803-648-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9335
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberPA2880
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: