Provider Demographics
NPI:1295795896
Name:FULFORD, RANDALL B (PA-C)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:B
Last Name:FULFORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7131 KING ARTHUR RD N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-4108
Mailing Address - Country:US
Mailing Address - Phone:904-338-1193
Mailing Address - Fax:
Practice Address - Street 1:96279 BRADY POINT RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-7076
Practice Address - Country:US
Practice Address - Phone:904-321-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004674363A00000X
FLPA3183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002029DMedicaid
GA100002029BMedicaid
GA01157676OtherAMERIGROUP
GA100002029CMedicaid
FL2909961-00Medicaid
GA01157676OtherAMERIGROUP
FL2909961-00Medicaid
GA100002029CMedicaid
GA100002029CMedicaid
FL2909961-00Medicaid