Provider Demographics
NPI:1275525164
Name:STROUP, RANDALL A (PAC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:A
Last Name:STROUP
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2755
Mailing Address - Country:US
Mailing Address - Phone:301-724-7616
Mailing Address - Fax:301-724-4811
Practice Address - Street 1:500 GREENE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2755
Practice Address - Country:US
Practice Address - Phone:301-724-7616
Practice Address - Fax:301-724-4811
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S68247Medicare UPIN