Provider Demographics
NPI:1013211630
Name:RANDALL, DANA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 S 8TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3519
Mailing Address - Country:US
Mailing Address - Phone:215-829-3493
Mailing Address - Fax:
Practice Address - Street 1:235 S 8TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3519
Practice Address - Country:US
Practice Address - Phone:215-829-3493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055363363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical