Provider Demographics
NPI:1891213658
Name:MORELAND, RANDI LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:LYNNE
Last Name:MORELAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:LYNNE
Other - Last Name:IRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:335 AGNES DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2202
Mailing Address - Country:US
Mailing Address - Phone:205-706-0499
Mailing Address - Fax:
Practice Address - Street 1:10435 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:FRONTENAC
Practice Address - State:MO
Practice Address - Zip Code:63131-2931
Practice Address - Country:US
Practice Address - Phone:314-985-3002
Practice Address - Fax:314-985-3012
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9110595363A00000X
IL085006651363A00000X
MO2018038670363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant