Provider Demographics
NPI:1194859751
Name:RANDOLPH, RONALD W (PA - PHYSICIAN ASST)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:W
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:PA - PHYSICIAN ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 - GALLBRAITH ROAD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236
Mailing Address - Country:US
Mailing Address - Phone:513-686-3000
Mailing Address - Fax:513-686-3001
Practice Address - Street 1:477 - GALLBRAITH ROAD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236
Practice Address - Country:US
Practice Address - Phone:513-686-3000
Practice Address - Fax:513-686-3001
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000447363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9111115Medicaid