Healthcare Provider Details

I. General information

NPI: 1407378136
Provider Name (Legal Business Name): TIMOTHY RICHARDSON PA.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 E WATER ST
SYRACUSE NY
13210-1155
US

IV. Provider business mailing address

100 METROPOLITAN PARK DR STE 100
LIVERPOOL NY
13088-7112
US

V. Phone/Fax

Practice location:
  • Phone: 315-478-4185
  • Fax: 315-478-0840
Mailing address:
  • Phone: 315-870-9369
  • Fax: 315-870-9364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036109
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: