Provider Demographics
NPI:1891875878
Name:MCCARTHY, RANDALL W (PA)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:W
Last Name:MCCARTHY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 KNIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-1943
Mailing Address - Country:US
Mailing Address - Phone:912-283-9423
Mailing Address - Fax:912-283-2946
Practice Address - Street 1:711 KNIGHT AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-1943
Practice Address - Country:US
Practice Address - Phone:912-283-9423
Practice Address - Fax:912-283-2946
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000666363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1891875878OtherMEDICARE NPI
GA476568664AMedicaid
GACG6045OtherRAILROAD MEDICARE GROUP ID
GACG6045OtherRAILROAD MEDICARE GROUP ID