Provider Demographics
NPI:1376093864
Name:RANDOLPH, ALTHEAL (PA)
Entity Type:Individual
Prefix:
First Name:ALTHEAL
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 COUNTY ROAD
Mailing Address - Street 2:
Mailing Address - City:JEMISON
Mailing Address - State:AL
Mailing Address - Zip Code:35085-3106
Mailing Address - Country:US
Mailing Address - Phone:205-908-8304
Mailing Address - Fax:205-688-2545
Practice Address - Street 1:340 COUNTY ROAD 126
Practice Address - Street 2:
Practice Address - City:JEMISON
Practice Address - State:AL
Practice Address - Zip Code:35085-3106
Practice Address - Country:US
Practice Address - Phone:205-908-8304
Practice Address - Fax:205-688-2545
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA190363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical