Provider Demographics
NPI:1619328465
Name:RANDOLPH, AMY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:RANDOLPH
Suffix:
Gender:F
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 1:66 PARKWAY LN
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2384
Mailing Address - Country:US
Mailing Address - Phone:540-451-2833
Mailing Address - Fax:
Practice Address - Street 1:66 PARKWAY LN
Practice Address - Street 2:SUITE 101A
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2384
Practice Address - Country:US
Practice Address - Phone:540-451-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110005390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant