Healthcare Provider Details

I. General information

NPI: 1104861368
Provider Name (Legal Business Name): STEPHEN L. RICHINS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 RIGBY LAKE DR STE. 114
RIGBY ID
83442-5229
US

IV. Provider business mailing address

1448 E CENTER ST SUITE E
POCATELLO ID
83201-4105
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-1300
  • Fax: 208-234-1333
Mailing address:
  • Phone: 208-234-1300
  • Fax: 208-234-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-931
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: