Provider Demographics
NPI:1558882241
Name:LEVESQUE, RANDY NEIL MARVIN (NURSE PRACTTIONER)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:NEIL MARVIN
Last Name:LEVESQUE
Suffix:
Gender:M
Credentials:NURSE PRACTTIONER
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-7205
Practice Address - Country:US
Practice Address - Phone:734-284-2026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704227414363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily