Provider Demographics
NPI:1033588330
Name:RANDEL, CODY (PA-C)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:RANDEL
Suffix:
Gender:M
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 1:7557 N DREAMY DRAW DR
Mailing Address - Street 2:UNIT 256
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4651
Mailing Address - Country:US
Mailing Address - Phone:773-663-5747
Mailing Address - Fax:
Practice Address - Street 1:3030 N CENTRAL AVE
Practice Address - Street 2:1407
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2707
Practice Address - Country:US
Practice Address - Phone:602-253-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant