Provider Demographics
NPI:1720004419
Name:BISHOP, RANDY LYMAN (MS)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LYMAN
Last Name:BISHOP
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 MEDICAL DR
Mailing Address - Street 2:#68
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-4034
Mailing Address - Fax:208-282-4571
Practice Address - Street 1:650 MEDICAL DR
Practice Address - Street 2:#68
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-4034
Practice Address - Fax:208-282-4571
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD 1225231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAU 761OtherBLUE CROSS
IDAU 761OtherBLUE CROSS