Provider Demographics
NPI:1427782549
Name:RANDALL, MELISA (PA)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N 2ND ST STE 204
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6130
Mailing Address - Country:US
Mailing Address - Phone:208-429-9100
Mailing Address - Fax:
Practice Address - Street 1:222 N 2ND ST STE 204
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6130
Practice Address - Country:US
Practice Address - Phone:208-429-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5836262471C3402X
IDPA-2359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography