Provider Demographics
NPI:1063496255
Name:RANDALL, AMBER LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LOUISE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1427
Mailing Address - Country:US
Mailing Address - Phone:928-777-9950
Mailing Address - Fax:928-777-9975
Practice Address - Street 1:1100 N SAN FRANCISCO ST STE E
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3260
Practice Address - Country:US
Practice Address - Phone:928-777-9950
Practice Address - Fax:928-777-9975
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34269207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ946725Medicaid
AZ103739Medicare ID - Type Unspecified
AZI11127Medicare UPIN