Provider Demographics
NPI:1902237167
Name:RICHARDSON, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 FALCONERS WAY
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-9022
Mailing Address - Country:US
Mailing Address - Phone:406-595-7181
Mailing Address - Fax:
Practice Address - Street 1:3400 LARAMIE DR
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2005
Practice Address - Country:US
Practice Address - Phone:406-587-0122
Practice Address - Fax:844-656-2480
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01774363AS0400X
MTMED-PAC-LIC-60845363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical