Provider Demographics
NPI:1629018411
Name:RANDOLPH, CARLA R (PA)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:R
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:305 PAUL BRYANT DR E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-2094
Mailing Address - Country:US
Mailing Address - Phone:205-345-0192
Mailing Address - Fax:205-247-2194
Practice Address - Street 1:305 PAUL BRYANT DR E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2094
Practice Address - Country:US
Practice Address - Phone:205-345-0192
Practice Address - Fax:205-247-2194
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-267363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51507969OtherBLUE CROSS BLUE SHIELD
ALP33360Medicare UPIN