Provider Demographics
NPI:1285680306
Name:EVERETT, RANDY W (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:W
Last Name:EVERETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 HOUSE AVE
Mailing Address - Street 2:STE 502
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3179
Mailing Address - Country:US
Mailing Address - Phone:307-635-4131
Mailing Address - Fax:307-635-6570
Practice Address - Street 1:2315 E HARMONY RD
Practice Address - Street 2:STE 140
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528
Practice Address - Country:US
Practice Address - Phone:970-484-6700
Practice Address - Fax:970-484-5723
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35652208800000X
CO30088208800000X
MT114117208800000X
WY9048A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01300888Medicaid
E56320Medicare UPIN
340006901Medicare PIN
CO01300888Medicaid