Provider Demographics
NPI:1710096458
Name:EDISON, RICHARD G (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:EDISON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2928
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2928
Mailing Address - Country:US
Mailing Address - Phone:425-207-5155
Mailing Address - Fax:
Practice Address - Street 1:1705 SE MEADOWBROOK BLVD STE 2
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1756
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:509-529-2858
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
WAPA10004152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1017094Medicaid
WA1710096458Medicaid
WA219156OtherL&I
WA315750OtherL&I POST 7/21/13
WA8944040OtherCV
WAP01256590OtherRR MEDICARE
WA315750OtherL&I POST 7/21/13