Provider Demographics
NPI:1013029735
Name:WILEY, RANDALL E (DC, MSN, ARNP)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:E
Last Name:WILEY
Suffix:
Gender:
Credentials:DC, MSN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23511 HOLLYWOOD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-5922
Mailing Address - Country:US
Mailing Address - Phone:301-997-0611
Mailing Address - Fax:
Practice Address - Street 1:23511 HOLLYWOOD RD STE 2
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-5922
Practice Address - Country:US
Practice Address - Phone:301-997-0611
Practice Address - Fax:855-253-1610
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556249111N00000X
MDR268981363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR268981OtherMARYLAND STATE LICENSE
VA0104556249OtherVA STATE LICENSE