Provider Demographics
NPI:1841233186
Name:SOUTHARDS, RANDALL R (PA)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:SOUTHARDS
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 GREENBRIER RD STE 320
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8320
Mailing Address - Fax:920-288-8325
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5703
Practice Address - Country:US
Practice Address - Phone:715-387-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41958200Medicaid
WI014607650Medicare ID - Type Unspecified
WIP41339Medicare UPIN