Provider Demographics
NPI:1437408887
Name:RANDOLPH, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RANDOLPH
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 1:1502 W NC HIGHWAY 54
Mailing Address - Street 2:STE 103
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5572
Mailing Address - Country:US
Mailing Address - Phone:919-354-0840
Mailing Address - Fax:919-748-4441
Practice Address - Street 1:529 NW 60TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2008
Practice Address - Country:US
Practice Address - Phone:352-331-5100
Practice Address - Fax:352-332-9607
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9315572163W00000X
FLARNP9315572363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse