Provider Demographics
NPI:1891980728
Name:RANDALL, CARRIE LINDA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:LINDA
Last Name:RANDALL
Suffix:
Gender:F
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 1:2525 CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-5088
Mailing Address - Country:US
Mailing Address - Phone:918-681-7533
Mailing Address - Fax:918-684-9033
Practice Address - Street 1:1505 E MAIN ST
Practice Address - Street 2:STIGLER HEALTH AND WELLNESS
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2913
Practice Address - Country:US
Practice Address - Phone:918-967-3368
Practice Address - Fax:918-967-3351
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1077570363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200122650AMedicaid
OK200122650AMedicaid