Provider Demographics
NPI:1588694103
Name:HUGHSTON, RANDY RAY (PA-C)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:RAY
Last Name:HUGHSTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 DAVID WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-1540
Mailing Address - Country:US
Mailing Address - Phone:801-936-5711
Mailing Address - Fax:
Practice Address - Street 1:982 CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4571
Practice Address - Country:US
Practice Address - Phone:801-479-4105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT282072-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTVADOOMedicare UPIN