Provider Demographics
NPI:1952394629
Name:RANDOLPH, MARK PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PATRICK
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3127
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895-3127
Mailing Address - Country:US
Mailing Address - Phone:252-243-2268
Mailing Address - Fax:252-243-2917
Practice Address - Street 1:2503 WOOTEN BLVD SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4426
Practice Address - Country:US
Practice Address - Phone:252-243-2268
Practice Address - Fax:252-243-2917
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC103783363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2758938Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
NCP92459Medicare UPIN