Provider Demographics
NPI:1124718796
Name:TOLLEY, RANDOLPH GARRETT (FNP-C)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:GARRETT
Last Name:TOLLEY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 SAMBA DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-6453
Mailing Address - Country:US
Mailing Address - Phone:910-207-3564
Mailing Address - Fax:
Practice Address - Street 1:14254 S PADRE ISLAND DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-6277
Practice Address - Country:US
Practice Address - Phone:615-894-0683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1066222363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily