Provider Demographics
NPI:1346960713
Name:PAUL, RANDALL T
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:T
Last Name:PAUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 TREBING PKWY
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-7796
Mailing Address - Country:US
Mailing Address - Phone:901-734-1928
Mailing Address - Fax:
Practice Address - Street 1:703 TREBING PKWY
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-7796
Practice Address - Country:US
Practice Address - Phone:901-734-1928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN061377689172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver