Provider Demographics
NPI:1669788725
Name:STINSON, RANDY DALE (DPT)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:DALE
Last Name:STINSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 WHITE SAGE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:UT
Mailing Address - Zip Code:84624-5555
Mailing Address - Country:US
Mailing Address - Phone:435-864-2551
Mailing Address - Fax:435-864-3573
Practice Address - Street 1:95 WHITE SAGE AVE STE C
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:UT
Practice Address - Zip Code:84624-5555
Practice Address - Country:US
Practice Address - Phone:435-864-2551
Practice Address - Fax:435-864-3573
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7702653-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1669788725Medicaid
UTU000072728Medicare UPIN