Provider Demographics
NPI:1730204108
Name:SHOUSE, RICHARD W (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:SHOUSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-364-8000
Mailing Address - Fax:
Practice Address - Street 1:500 E 84TH AVE
Practice Address - Street 2:SUITE B-14
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-5309
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO305869Medicare UPIN
COCOB4545Medicare PIN