Healthcare Provider Details

I. General information

NPI: 1336157833
Provider Name (Legal Business Name): RICHARD D EDGERLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 AHTANUM RIDGE DR
UNION GAP WA
98903-1839
US

IV. Provider business mailing address

1020 S 40TH AVE STE A
YAKIMA WA
98908-3800
US

V. Phone/Fax

Practice location:
  • Phone: 509-454-7700
  • Fax: 509-454-7710
Mailing address:
  • Phone: 509-823-4650
  • Fax: 509-823-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00034059
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: