Provider Demographics
NPI:1447666508
Name:RICH, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:RICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1413
Mailing Address - Country:US
Mailing Address - Phone:505-400-8556
Mailing Address - Fax:
Practice Address - Street 1:549 FAIR ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1419
Practice Address - Country:US
Practice Address - Phone:505-400-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2244382085R0202X, 208D00000X
NMPA2014-0023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical