Provider Demographics
NPI:1396398988
Name:WILLIAMS, RANDY
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:WILLIAMS
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 1:327 WILDER BLVD APT B302
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-7022
Mailing Address - Country:US
Mailing Address - Phone:386-275-9732
Mailing Address - Fax:
Practice Address - Street 1:1665 M ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1121
Practice Address - Country:US
Practice Address - Phone:386-275-9732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA48969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant