Provider Demographics
NPI:1235654435
Name:PEREZ, RANDY GONZALO (CSFA)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:GONZALO
Last Name:PEREZ
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 221135
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-1135
Mailing Address - Country:US
Mailing Address - Phone:703-349-1379
Mailing Address - Fax:
Practice Address - Street 1:12011 LEE JACKSON MEMORIAL HWY STE 501
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033
Practice Address - Country:US
Practice Address - Phone:703-349-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant