Provider Demographics
NPI:1811103690
Name:STAMBAUGH, RANDY LEE (PTA)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LEE
Last Name:STAMBAUGH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:720 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1747
Mailing Address - Country:US
Mailing Address - Phone:989-723-6261
Mailing Address - Fax:
Practice Address - Street 1:216 E COMSTOCK ST STE C
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-3161
Practice Address - Country:US
Practice Address - Phone:989-729-2929
Practice Address - Fax:989-729-6481
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant