Provider Demographics
NPI:1770092959
Name:MCDERMOTT, RANDY CHARLES (PTA)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:CHARLES
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:HARDING
Mailing Address - State:PA
Mailing Address - Zip Code:18643-3019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 PIERCE ST STE 207
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5141
Practice Address - Country:US
Practice Address - Phone:808-348-0979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004678225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant