Provider Demographics
NPI:1588609440
Name:ORSBORN, RANDY L (PAC)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:L
Last Name:ORSBORN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1330 COSHOCTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1440
Mailing Address - Country:US
Mailing Address - Phone:740-393-9111
Mailing Address - Fax:740-399-3161
Practice Address - Street 1:1490 COSHOCTON AVE
Practice Address - Street 2:STE B
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-6099
Practice Address - Country:US
Practice Address - Phone:740-393-9111
Practice Address - Fax:740-399-3161
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31821Medicare UPIN
ORPA17233Medicare PIN