Provider Demographics
NPI:1578590782
Name:RANDAZZO, STEPHEN (NP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:RANDAZZO
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 1:1485 N TURQUOISE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-774-7757
Mailing Address - Fax:928-226-3071
Practice Address - Street 1:1485 N TURQUOISE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1398
Practice Address - Country:US
Practice Address - Phone:928-774-7757
Practice Address - Fax:928-226-3071
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1186363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ911322Medicaid
AZ911322Medicaid
AZZ101192Medicare PIN