1104861368 NPI number — STEPHEN L. RICHINS PA-C

Table of content: STEPHEN L. RICHINS PA-C (NPI 1104861368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104861368 NPI number — STEPHEN L. RICHINS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHINS
Provider First Name:
STEPHEN
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104861368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1448 E CENTER ST
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-4105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-234-1300
Provider Business Mailing Address Fax Number:
208-234-1333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 RIGBY LAKE DR
Provider Second Line Business Practice Location Address:
STE. 114
Provider Business Practice Location Address City Name:
RIGBY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83442-5229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-1300
Provider Business Practice Location Address Fax Number:
208-234-1333
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA-931 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 328390099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 970027996 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: P00993652 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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