MEDICARE: KEIGHLEY FAYE RICHARDSON PA-C, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	1675	AZ
2	363A00000X	Physician Assistant	8972	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326559790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEIGHLEY FAYE RICHARDSON PA-C, ATC

Provider Business Mailing Address
First Line	:	PO BOX 2253
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85002-2253
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3330 N 2ND ST STE 401
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2371
Country	:	US
Telephone Number	:	602-606-8949
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2017
Last Update Date	:	11/26/2022

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