Provider Demographics
NPI:1629058375
Name:NANCE, RANDALL L (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:NANCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:RANDY
Other - Middle Name:LYNN
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:200 GREENBRIAR LOOP
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2760
Mailing Address - Country:US
Mailing Address - Phone:601-513-2401
Mailing Address - Fax:
Practice Address - Street 1:120-HWY 6 W
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606
Practice Address - Country:US
Practice Address - Phone:662-360-1789
Practice Address - Fax:662-360-1791
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10479207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116402Medicaid
B64155Medicare UPIN