Provider Demographics
NPI:1326113242
Name:RANDOLPH, CYNTHIA (PAC)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12547 OCEAN GATEWAY
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-9341
Mailing Address - Country:US
Mailing Address - Phone:410-213-0119
Mailing Address - Fax:410-213-2875
Practice Address - Street 1:12547 OCEAN GATEWAY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9341
Practice Address - Country:US
Practice Address - Phone:410-213-0119
Practice Address - Fax:410-213-2875
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002701363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1032642OtherP.A.C. CERTIFICATION
DEC5-0000497OtherP.A. LICENSE
MDC0002701OtherP.A, LICENSE
DEPA0202OtherPRESCRIBE NARCOTICS
MDPA55377OtherLICENSE TO PRESCRIBE CONT
MDPA55377OtherLICENSE TO PRESCRIBE CONT
MD1032642OtherP.A.C. CERTIFICATION