Provider Demographics
NPI:1821474230
Name:RANDHAWA, SUPINDER KAUR (NP)
Entity Type:Individual
Prefix:
First Name:SUPINDER
Middle Name:KAUR
Last Name:RANDHAWA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 BLUE OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7143
Mailing Address - Country:US
Mailing Address - Phone:916-784-7546
Mailing Address - Fax:
Practice Address - Street 1:1412 BLUE OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-7143
Practice Address - Country:US
Practice Address - Phone:916-784-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002473363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner