Healthcare Provider Details

I. General information

NPI: 1073395232
Provider Name (Legal Business Name): DANIEL J RICHARDSON C-AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

PO BOX 22407
SAINT LOUIS MO
63126-0407
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1000
  • Fax:
Mailing address:
  • Phone: 636-386-7222
  • Fax: 636-386-7810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPENDING
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: