Provider Demographics
NPI:1205024866
Name:CUPP, RANDAL CURTIS (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:CURTIS
Last Name:CUPP
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:RANDAI
Other - Middle Name:CURTIS
Other - Last Name:CUPP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:203 S. WESTERN AVE
Mailing Address - Street 2:C/O: CREDENTIALING
Mailing Address - City:TONASKET
Mailing Address - State:WA
Mailing Address - Zip Code:98855
Mailing Address - Country:US
Mailing Address - Phone:509-486-3144
Mailing Address - Fax:
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6341
Practice Address - Fax:253-426-6344
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0225542OtherSTATE L&I
WA8498388Medicaid
WA0302340OtherSTATE L&I
WAP00704522OtherRAILROAD
WA8945631OtherSTATE CRIME VICTIMS
WAP00704522OtherRAILROAD
WA8498388Medicaid
WAG8913275Medicare PIN