Provider Demographics
NPI:1861875023
Name:RICHARDSON, ISAIAH ALEXANDER
Entity type:Individual
Prefix:
First Name:ISAIAH
Middle Name:ALEXANDER
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3027 NORTHWOOD DR APT 111
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3928
Mailing Address - Country:US
Mailing Address - Phone:910-551-4729
Mailing Address - Fax:336-985-2122
Practice Address - Street 1:167 MOORE RD
Practice Address - Street 2:
Practice Address - City:KING
Practice Address - State:NC
Practice Address - Zip Code:27021-8770
Practice Address - Country:US
Practice Address - Phone:336-985-2120
Practice Address - Fax:336-985-2122
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant