Provider Demographics
NPI:1073559373
Name:CARTER, RANDALL ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:ALLEN
Last Name:CARTER
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 1:1400 SE 4TH ST STE H
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7328
Mailing Address - Country:US
Mailing Address - Phone:405-799-7400
Mailing Address - Fax:405-799-7405
Practice Address - Street 1:1400 SE 4TH ST STE H
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160
Practice Address - Country:US
Practice Address - Phone:405-799-7400
Practice Address - Fax:405-799-7405
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1045363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1045OtherOKLAHOMA BOARD OF MEDICAL LICENSURE