Provider Demographics
NPI:1033250212
Name:MYERS, RANDALL SHANE
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:SHANE
Last Name:MYERS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ROY
Other - Middle Name:RUSSELL
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPED
Mailing Address - Street 1:21 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-4909
Mailing Address - Country:US
Mailing Address - Phone:580-470-9490
Mailing Address - Fax:580-470-9502
Practice Address - Street 1:21 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4909
Practice Address - Country:US
Practice Address - Phone:580-470-9490
Practice Address - Fax:580-470-9502
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13-D-1200332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
201453400001OtherBCBS
201453400001OtherBCBS