Provider Demographics
NPI:1942720222
Name:RANDALL, NATHAN JAMES (FNP)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JAMES
Last Name:RANDALL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 CYPRESS POINT LN APT 203
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6097
Mailing Address - Country:US
Mailing Address - Phone:907-250-9314
Mailing Address - Fax:
Practice Address - Street 1:4360 E MAIN ST UNIT B2
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-8279
Practice Address - Country:US
Practice Address - Phone:805-290-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95011888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily