Provider Demographics
NPI:1902413743
Name:EVERSDYK, RANDALL DEAN (RN)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:DEAN
Last Name:EVERSDYK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ALLEGRIA DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-2347
Mailing Address - Country:US
Mailing Address - Phone:325-514-9778
Mailing Address - Fax:
Practice Address - Street 1:104 ALLEGRIA DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-2347
Practice Address - Country:US
Practice Address - Phone:325-514-9778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX866215163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse