Provider Demographics
NPI:1982793568
Name:RANDALL, JOEL DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:DAVID
Last Name:RANDALL
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 1:122 W 7TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2301
Mailing Address - Country:US
Mailing Address - Phone:509-462-6485
Mailing Address - Fax:
Practice Address - Street 1:104 W 5TH AVE
Practice Address - Street 2:SUITE 400W
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-4880
Practice Address - Country:US
Practice Address - Phone:509-353-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005090363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant