Provider Demographics
NPI:1285091116
Name:HAILEY, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:HAILEY
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 1:3324 FRENCH PARK DR STE D
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7262
Mailing Address - Country:US
Mailing Address - Phone:405-715-3610
Mailing Address - Fax:405-715-3612
Practice Address - Street 1:9600 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7408
Practice Address - Country:US
Practice Address - Phone:405-486-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103037367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered