Provider Demographics
NPI:1033616719
Name:PROVINCE, RANDY LEE
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:PROVINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RANDY LEE RATCLIFF
Mailing Address - Street 1:229 MORRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:VA
Mailing Address - Zip Code:24136-3003
Mailing Address - Country:US
Mailing Address - Phone:304-685-1732
Mailing Address - Fax:
Practice Address - Street 1:911 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-4183
Practice Address - Country:US
Practice Address - Phone:540-745-0231
Practice Address - Fax:540-745-4028
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program