Provider Demographics
NPI:1396567913
Name:AGPASAN, RANDII (SUDRC)
Entity type:Individual
Prefix:
First Name:RANDII
Middle Name:
Last Name:AGPASAN
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6293
Mailing Address - Country:US
Mailing Address - Phone:707-718-4872
Mailing Address - Fax:
Practice Address - Street 1:1095 E TABOR AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4190
Practice Address - Country:US
Practice Address - Phone:707-718-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11039171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator