Provider Demographics
NPI:1356656342
Name:DANIELSEN, RANDY DEE (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DEE
Last Name:DANIELSEN
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:428 S GILBERT RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-2263
Mailing Address - Country:US
Mailing Address - Phone:480-633-3639
Mailing Address - Fax:888-372-6991
Practice Address - Street 1:9220 E MOUNTAIN VIEW RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5133
Practice Address - Country:US
Practice Address - Phone:480-451-6756
Practice Address - Fax:480-451-8679
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1081363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical