Provider Demographics
NPI:1508060237
Name:RANDALL KOAYEN, OTERIA
Entity Type:Individual
Prefix:MRS
First Name:OTERIA
Middle Name:
Last Name:RANDALL KOAYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OTERIA
Other - Middle Name:RANDALL
Other - Last Name:KOAYEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1166 BROOKTRAIL DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-7627
Mailing Address - Country:US
Mailing Address - Phone:925-261-9953
Mailing Address - Fax:
Practice Address - Street 1:1166 BROOKTRAIL DR
Practice Address - Street 2:1900 FRUITVALE AVE SUITE 3E
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-7627
Practice Address - Country:US
Practice Address - Phone:925-261-9953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15439363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine