Provider Demographics
NPI:1124262423
Name:ANTLE, RANDAL PAIGE (PA-C)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:PAIGE
Last Name:ANTLE
Suffix:
Gender:F
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 1:2665 N DECATUR RD
Mailing Address - Street 2:SUITE 650
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6149
Mailing Address - Country:US
Mailing Address - Phone:404-508-0566
Mailing Address - Fax:404-508-0567
Practice Address - Street 1:1951 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3415
Practice Address - Country:US
Practice Address - Phone:404-321-4600
Practice Address - Fax:404-320-0987
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1875363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I979208Medicare PIN