Provider Demographics
NPI:1437155918
Name:MCDUFFY, RANDY L
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:L
Last Name:MCDUFFY
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 1:1507 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1132
Mailing Address - Country:US
Mailing Address - Phone:662-423-1000
Mailing Address - Fax:662-423-1316
Practice Address - Street 1:1507 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1132
Practice Address - Country:US
Practice Address - Phone:662-423-1000
Practice Address - Fax:662-423-1316
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR803373363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02353870Medicaid
MS02353870Medicaid