Healthcare Provider Details

I. General information

NPI: 1255121638
Provider Name (Legal Business Name): MICHAEL DALLIN RICHARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 S WASHINGTON ST STE 101
CASPER WY
82601-2951
US

IV. Provider business mailing address

419 S WASHINGTON ST STE 101
CASPER WY
82601-2951
US

V. Phone/Fax

Practice location:
  • Phone: 307-265-1620
  • Fax: 307-237-1074
Mailing address:
  • Phone: 307-265-1620
  • Fax: 307-237-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: