Provider Demographics
NPI:1558970517
Name:BARGO, RANDY (NP)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:BARGO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 DOWELL SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2441
Mailing Address - Country:US
Mailing Address - Phone:865-970-9800
Mailing Address - Fax:
Practice Address - Street 1:1451 DOWELL SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2441
Practice Address - Country:US
Practice Address - Phone:865-970-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010173A363LP0808X
TN28859363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ066255Medicaid