Provider Demographics
NPI:1982076246
Name:RANDOLPH, RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:1094 RIVER ISLE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-8870
Mailing Address - Country:US
Mailing Address - Phone:912-667-0714
Mailing Address - Fax:
Practice Address - Street 1:1094 RIVER ISLE DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-8870
Practice Address - Country:US
Practice Address - Phone:912-667-0714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant