Provider Demographics
NPI:1841774486
Name:BAIN, RANDY E (PA-C, MPHC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:E
Last Name:BAIN
Suffix:
Gender:M
Credentials:PA-C, MPHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SHORELINE DR UNIT 1565
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-7339
Mailing Address - Country:US
Mailing Address - Phone:480-332-7771
Mailing Address - Fax:
Practice Address - Street 1:2670 S WHITE RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2073
Practice Address - Country:US
Practice Address - Phone:408-729-4290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant