Provider Demographics
NPI:1821291881
Name:SCHULTZE, RANDALL E (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:E
Last Name:SCHULTZE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 BRONSON BLVD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3211
Mailing Address - Country:US
Mailing Address - Phone:269-383-8202
Mailing Address - Fax:
Practice Address - Street 1:411 NAOMI ST
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1222
Practice Address - Country:US
Practice Address - Phone:269-685-0796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC96038061Medicare PIN