Healthcare Provider Details

I. General information

NPI: 1538376538
Provider Name (Legal Business Name): RICHARD CLINTON VAUSE JR. PA-C, DHSC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 DIAMOND ST KENSINGTON HOSPITAL
PHILADELPHIA PA
19122-1721
US

IV. Provider business mailing address

8470 LIMEKILN PIKE APT 724
WYNCOTE PA
19095-2701
US

V. Phone/Fax

Practice location:
  • Phone: 215-426-8100
  • Fax:
Mailing address:
  • Phone: 267-627-2613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA 000373L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9103393
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: