Provider Demographics
NPI:1508825357
Name:JACKSON, RANDY D (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-1258
Mailing Address - Country:US
Mailing Address - Phone:207-723-5173
Mailing Address - Fax:207-723-3040
Practice Address - Street 1:200 SOMERSET ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-1258
Practice Address - Country:US
Practice Address - Phone:207-723-5173
Practice Address - Fax:207-723-3040
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME079032OtherANTHEM
ME201855OtherNGS
ME1508825357Medicaid
ME1508825357Medicaid