Provider Demographics
NPI:1033275227
Name:RANDOLPH-CLARK, PATRICIA ANN (RN, ANP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:RANDOLPH-CLARK
Suffix:
Gender:F
Credentials:RN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WOODRUFF ST
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-1715
Mailing Address - Country:US
Mailing Address - Phone:518-891-5484
Mailing Address - Fax:518-891-5484
Practice Address - Street 1:25 WOODRUFF ST
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1715
Practice Address - Country:US
Practice Address - Phone:518-891-5484
Practice Address - Fax:518-891-5484
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301713363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB4297Medicare ID - Type Unspecified