Provider Demographics
NPI:1639209448
Name:RANDALL, MICHAEL L (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-494-4949
Mailing Address - Fax:706-494-4940
Practice Address - Street 1:101 13TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2101
Practice Address - Country:US
Practice Address - Phone:706-494-4949
Practice Address - Fax:706-494-4940
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-517363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPA-517OtherSTATE LICENSE
GA005031OtherLICENSE