Provider Demographics
NPI:1174508121
Name:RANDOLPH, CHRISTA DAWN (MPT)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:DAWN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1751
Mailing Address - Country:US
Mailing Address - Phone:304-842-3137
Mailing Address - Fax:304-842-3138
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1751
Practice Address - Country:US
Practice Address - Phone:304-842-3137
Practice Address - Fax:304-842-3138
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002526174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRA4173722Medicare PIN
WVRA4173721Medicare PIN