Provider Demographics
NPI:1528440971
Name:MCCREERY, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:MCCREERY
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3939 J ST STE 320
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3666
Practice Address - Country:US
Practice Address - Phone:916-733-5995
Practice Address - Fax:916-281-3862
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA167301207R00000X
NE7521207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE7521OtherNEBRASKA STATE MEDICAL BOARD