Provider Demographics
NPI:1558071811
Name:RANDY, DUSTIN SAMUEL (PA-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:SAMUEL
Last Name:RANDY
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 1:2845 SIENA HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4153
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:
Practice Address - Street 1:2845 SIENA HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4153
Practice Address - Country:US
Practice Address - Phone:702-877-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant