MEDICARE: WILLIAM DEREK RICHARDSON

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1177	OTHER	NE	LICENSE #

General Provider Information

NPI Number	:	1487763058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM DEREK RICHARDSON

Provider Business Mailing Address
First Line	:	3924 MINEOLA WAY
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-0465
Country	:	US
Telephone Number	:	702-251-8477
Fax Number	:

Provider Business Practice Location Address
First Line	:	821 N NELLIS BLVD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-5387
Country	:	US
Telephone Number	:	702-452-4563
Fax Number	:

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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