Healthcare Provider Details

I. General information

NPI: 1134478100
Provider Name (Legal Business Name): RICHARD EDWARD HURST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4753 ORCAS ST NE
LACEY WA
98516-6645
US

IV. Provider business mailing address

4753 ORCAS ST NE
LACEY WA
98516-6645
US

V. Phone/Fax

Practice location:
  • Phone: 360-866-1116
  • Fax:
Mailing address:
  • Phone: 360-866-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00011101
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: