Healthcare Provider Details

I. General information

NPI: 1245285840
Provider Name (Legal Business Name): TASHA L RICHARDS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 WASHINGTON ST
WATERTOWN NY
13601
US

IV. Provider business mailing address

PO BOX 91
WATERTOWN NY
13601
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-9003
  • Fax: 315-782-9010
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007134
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: