Provider Demographics
NPI:1255740411
Name:RICHARDSON, JAMIE (CRNA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1141
Mailing Address - Country:US
Mailing Address - Phone:304-329-1400
Mailing Address - Fax:304-329-1175
Practice Address - Street 1:150 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1141
Practice Address - Country:US
Practice Address - Phone:304-329-1400
Practice Address - Fax:304-329-1175
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL102842367500000X
WVAPRN96208367500000X
NM76117367500000X
WV96208367500000X
AZCRNA 1064367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ170838Medicare PIN