Provider Demographics
NPI:1245889310
Name:RANDAZZO, VICTORIA PHAM (PHD, AG-NP, RN)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:PHAM
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:PHD, AG-NP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7745 E WALNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-6515
Mailing Address - Country:US
Mailing Address - Phone:714-743-9494
Mailing Address - Fax:
Practice Address - Street 1:13522 NEWPORT AVE STE 102
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3707
Practice Address - Country:US
Practice Address - Phone:714-573-8200
Practice Address - Fax:714-573-9401
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012573363L00000X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95012573OtherNURSE PRACTITIONER FURNISHING LICENSE