Provider Demographics
NPI:1114066289
Name:RANDALL, JON CHARLES (PA)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:CHARLES
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 827 BOX 382
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09617
Mailing Address - Country:IT
Mailing Address - Phone:081-811-6271
Mailing Address - Fax:
Practice Address - Street 1:PSC 827 BOX 382
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09617
Practice Address - Country:IT
Practice Address - Phone:081-811-6271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1049777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant