Provider Demographics
NPI:1861572687
Name:RICHARD, RAE (CRNP)
Entity type:Individual
Prefix:MS
First Name:RAE
Middle Name:
Last Name:RICHARD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 560
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-452-0306
Mailing Address - Fax:858-452-1421
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 560
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-452-0306
Practice Address - Fax:858-452-1421
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP9853363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNP9853AMedicare ID - Type Unspecified
CAS87911Medicare UPIN