Provider Demographics
NPI:1386386316
Name:RANDELL, MEGHAN SPROUSE
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:SPROUSE
Last Name:RANDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2827 PRESTON PARK WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:VA
Mailing Address - Zip Code:23153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 BROWNS WAY RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-9501
Practice Address - Country:US
Practice Address - Phone:804-419-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110008844OtherLICENSE