Provider Demographics
NPI:1215798327
Name:ABBOTT, RANDY WAYNE
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:WAYNE
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MEREDITH LN
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-3340
Mailing Address - Country:US
Mailing Address - Phone:440-724-2158
Mailing Address - Fax:
Practice Address - Street 1:602 MEREDITH LN
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-3340
Practice Address - Country:US
Practice Address - Phone:440-724-2158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPQ498209172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver