Provider Demographics
NPI:1902208358
Name:RANDALL, EMILY MARIE (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5255 E STOP 11 RD STE 450
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6342
Practice Address - Country:US
Practice Address - Phone:317-865-4800
Practice Address - Fax:317-865-4806
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2023-09-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9108234363AM0700X
IN10003350A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical