Provider Demographics
NPI:1306981378
Name:HEATH, RANDOLPH W (PA-C)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:W
Last Name:HEATH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:120 HEALTH PARK BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5798
Mailing Address - Country:US
Mailing Address - Phone:904-823-3401
Mailing Address - Fax:904-829-8649
Practice Address - Street 1:120 HEALTH PARK BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5798
Practice Address - Country:US
Practice Address - Phone:904-823-3401
Practice Address - Fax:904-829-8649
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical