Provider Demographics
NPI:1821007865
Name:SEIDEHAMEL, RANDALL J (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:SEIDEHAMEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 E PARRISH AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-926-4100
Mailing Address - Fax:270-684-4678
Practice Address - Street 1:2831 NEW HARTFORD RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1320
Practice Address - Country:US
Practice Address - Phone:270-926-4100
Practice Address - Fax:270-684-4678
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S87797Medicare UPIN
KYK013381Medicare PIN