Provider Demographics
NPI:1669464236
Name:MAHONEY, RANDOLPH BARRET (PA-C, PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:BARRET
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:PA-C, PHD
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 42
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-0042
Mailing Address - Country:US
Mailing Address - Phone:904-354-4488
Mailing Address - Fax:904-634-8912
Practice Address - Street 1:1541 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4124
Practice Address - Country:US
Practice Address - Phone:904-354-4488
Practice Address - Fax:904-634-8912
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101713363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6699YMedicare PIN