Provider Demographics
NPI:1235162892
Name:RANDALL, PHYLLIS ELAINE (PA)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ELAINE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 HORSESHOE RD
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-6028
Mailing Address - Country:US
Mailing Address - Phone:845-677-9544
Mailing Address - Fax:
Practice Address - Street 1:3 CHARLES ST
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569-7703
Practice Address - Country:US
Practice Address - Phone:845-635-2650
Practice Address - Fax:845-635-2433
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001537363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02389086Medicaid
NY02389086Medicaid