Provider Demographics
NPI:1700225174
Name:POBLETE, RANDALL JOSEPH PUNU (MSPAS, MPH, PA-C)
Entity Type:Individual
Prefix:MR
First Name:RANDALL JOSEPH
Middle Name:PUNU
Last Name:POBLETE
Suffix:
Gender:M
Credentials:MSPAS, MPH, PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:275 BECK AVE
Mailing Address - Street 2:PO BOX 4090 MS-5-240
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6804
Mailing Address - Country:US
Mailing Address - Phone:707-784-2028
Mailing Address - Fax:
Practice Address - Street 1:275 BECK AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6804
Practice Address - Country:US
Practice Address - Phone:707-784-2028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA23021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant