Provider Demographics
NPI:1285992164
Name:RANDALL, LISA MARIE (CERTTECH)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:CERTTECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 COUNTY ROUTE 56
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676
Mailing Address - Country:US
Mailing Address - Phone:315-212-7817
Mailing Address - Fax:
Practice Address - Street 1:970 COUNTY ROUTE 56
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-3351
Practice Address - Country:US
Practice Address - Phone:315-212-7817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1912269226OtherGROUP NPI