Provider Demographics
NPI:1164401097
Name:COOPERMAN, RANDI BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:BETH
Last Name:COOPERMAN
Suffix:
Gender:F
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:PO BOX 860554
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-0554
Mailing Address - Country:US
Mailing Address - Phone:904-346-3606
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:3625 UNIVERSITY BLVD S
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4207
Practice Address - Country:US
Practice Address - Phone:904-346-3606
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
U2292YMedicare ID - Type Unspecified
FLQ17288Medicare UPIN