Provider Demographics
NPI:1790320620
Name:RANDOLPH, DILLON ANDREW
Entity Type:Individual
Prefix:
First Name:DILLON
Middle Name:ANDREW
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3332 HUNTLEY DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3836
Mailing Address - Country:US
Mailing Address - Phone:562-619-0647
Mailing Address - Fax:
Practice Address - Street 1:3332 HUNTLEY DR
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3836
Practice Address - Country:US
Practice Address - Phone:562-619-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant