Provider Demographics
NPI:1134699911
Name:RICHARDS, KENNETH (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25012 DIANA CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-7165
Mailing Address - Country:US
Mailing Address - Phone:815-666-6114
Mailing Address - Fax:
Practice Address - Street 1:1356 NW BOCA RATON BLVD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1609
Practice Address - Country:US
Practice Address - Phone:864-625-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant